Triangle ENT Services Assoc., PA

Consent for Release of Medical Information

My clinic notes, lab reports, x-ray reports and any other material regarding medical consultation and treatment I received from Triangle ENT and Allergy.
Records may be sent via
I understand that once my records are sent, they will no longer be within Triangle ENT's control and might be re-released by the recipient.
We will make every effort to fulfill requests in a timely manner as they are received. A small fee may apply to larger volumes.
Signature of Patient or Legal Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
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