Consent for release of information records

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CONSENT FOR RELEASE OF INFORMATION/RECORDS

DATE:

PATIENT'S NAME:

DATE OF BIRTH:

I HEREBY GIVE MY PERMISSION FOR: _____Dallas Podiatry Works_ _ (Name of agency, hospital, doctor, etc...)

TO RELEASE OR DISCLOSE TO:

THE FOLLOWING INFORMATION:

Medical Records Lab/Imaging Reports X-rays Other______________ FOR THE PERIOD ______________________________

I AUTHORIZE DR. BROOK AND DR. NORTHCUTT/DALLAS PODIATRY WORKS AND/OR HIS REPRESENTATIVE TO DISCUSS MY MEDICAL INFORMATION WITH

THIS CONSENT IS SUBJECT TO REVOCATION AT ANY TIME IN THE FORM OF WRITTEN NOTICE FROM ME

Patient Signature: ______________________________________ Date_____________

Parent Signature: ____________________________________ Date____________

Witness Signature: _________________________________

Date______________

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