Free 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:
Release Form Templates @ Template.net
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Simplify permissions with the editable Pediatrics Medical Release Form Template from Template.net, specifically designed for healthcare providers! This template offers a professional structure that is fully customizable to meet different medical scenarios. The AI Editor Tool allows for quick adjustments, ensuring accurate and comprehensive documentation of parental consents and medical releases for pediatric patients, enhancing operational efficiency!