Consent for Release of Medical Information
I,
HEREBY AUTHORIZE TRIANGLE ENT AND ALLERGY TO RELEASE TO: (PCP, Specialist, Self, Parent or Guardian):
Name
Address
City
State
Zip
Phone
Fax
Email Address
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
Email or
Fax
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.
Date