Records Release Form

NORTH COUNTRY EYE CARE ASSOCIATES

10 Benning Street, Suite 10
West Lebanon, NH
Phone: (603) 678-4759 / Fax: (603) 790-8047

To Health Care Provider

Phone

Fax

Patient (Please Print)

DOB

The above mentioned patient (or Guardian/Caretaker) has authorized release of their records to North Country Eye Care Associates. PLEASE SEND EYE CARE/VISION RECORDS ONLY

The above mentioned patient has authorized North Country Eye Care Associates to release their records to your office.

Please select

I hereby authorize release of any information, including the ocular and refractive diagnoses, findings and records of any treatment from pertinent visit(s). Thank you for your prompt attention to this request.

Patient's Signature (Parent's signature if the patient is a minor )

Date

Guardian/Caretaker Signature

Date