Release of Records

Patient Name(Required)

First Last

Date of Birth(Required)

PLEASE RELEASE COPIES OF THE FOLLOWING RECORDS PER MY REQUEST:(Required)

Complete eye care records

Current exam and prescription(s)

Current prescription(s) only

Records from only a specific Date of Service

Enter specific Date of Service(Required)

I hereby request the release of records to the person listed below:

Please send my information via:(Required)

FAX (Free)

Mail ($25.00)

Address

Street Address Address Line 2 City State ZIP Code

Fax Phone

Signature

Parent or Guardian

Orthokeratology