Medical Records Release Form

Today's Date:

Patient Name:

Patient Signature:

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Patient Date of Birth:

Parent or Legal Guardian Name:

Parent or Legal Guardian Signature:

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Date of Service by Cherokee Fire E-S:

Requested Information:

Person to whom information is released:
Patient Other (Specify)

Verify I.D:
Yes No

Type of I.D.:

Attach a photo of I.D.: