Release of Medical Information Authorization

(541) 382-8819 Schedule Appointment Patient Portal

Date
Date Format: MM slash DD slash YYYY
I give my consent to Dermatology Health Specialists, P.C. to receive my records from:
Provider Name
Provider Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Provider Phone
Patient Date of Birth
Date Format: MM slash DD slash YYYY
Patient Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Type of record requested
- Path/Lab report(s)
- Office note(s)
- Photo(s)
- Entire Medical Record(s)
- Other (specify below)
Other
Name
First Last