Records Release for Patients in Treatment

Date *

To Nelson R. Diers

I hereby authorize you to release to

Doctor(s) Name *

all information including the diagnosis and records of any treatment or examination rendered to me.

Doctor's Email for Records Release *

[email protected]

Patient Name *

Date of birth *

Email *

Address

Street Address *

City *

State *

Postal Code *

Patient's Signature (if a minor - parent or guardian signature) *

Clear

Phone *

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

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