Free Pediatrics Medical Release Form Template
Pediatrics Medical Release Form
Please complete this form to authorize the release of medical information.
Patient Information
Name
Date of Birth
Parent/Guardian
Phone Number
Address
Medical Information to Be Released
Select all that apply:
-
Immunization Records
-
Medical History
-
Treatment Records
-
Recipient Information
Recipient/Organization Name
Address
Authorization
By signing below, I authorize the release of my child’s medical records as described above. I understand that these records will be shared with the designated parties for healthcare purposes. I also acknowledge that this authorization is voluntary, and I can revoke it at any time by providing written notice to the healthcare provider.
Name:
Date:
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