AFFZ11 Medical Records Release Form

Medical Records Release
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
I hereby authorize Affiliated Dermatologists, S.C. to release my medical records to:
Doctor or Facility*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number*
Please enter a valid phone number.
Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Patient Signature*

Clear
Date*

MonthDayYear
Date
Date*

MonthDayYear
Date
Should be Empty: