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Medical Release Form

This medical release form template has a simple purpose, to give consent that the patient’s information can be released by their healthcare provider to someone other than the patient. Check out the template below:

Patient Name *

First

Last

Date of Birth *

Patient Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Phone *

MEDICAL RECORDS INFORMATION

I Hereby Request That My Medical Records Be Released To: *

Physician/Clinic's Name

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Medical Records Release Terms & Conditions *

This is where we'd put your full terms and conditions for your release form. This field is marked as required and has to be ticked to be submitted.

1. YOUR AGREEMENT

By agreeing to this release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box.

PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.

Patient's Signature *

Date *

MEDICAL RECORDS INFORMATION

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