Medical Record Release Form

 Please print all 3 pages plus the adult or 0-17yr form.

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*Our office has every patient fill out these forms once a year. If any demographic or insurance information changes within the year, please complete page 1 again.

As of June 1 ,2017 we have updated to text and email confirmations. We also communicate when there are openings in our schedule through text or emails. Please call to update your cell phone and email address.