Medical Records Release Form

Elias Darido, MD, FACS

Houston Heartburn & Reflux Center

Houston Weight Loss Surgery Center

Date Of Birth *

Please list below the physicians that have the above requested reports.(Name, Phone number, Fax)

I , authorize the release of information including the diagnosis, records, and examination rendered to me by the physicians listed above to Dr. Elias Darido.

(Ph. 832-945-8717)

(Fax# 281-762-1452)

Patient Signature *

Clear

Date *