Medical Release Form
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Email *
Name of Client *
Date of Birth *
MM
/
DD
/
YYYY
Email address
Name of person completing this form if different from client
Type of information to be release *
Purpose of information being released *
Release Information to the Following
Name *
Phone *
Email *
Fax
Mailing address
Delivery method *
Continued Medical Care *
Release Date Expiration (recommendation is one year past today's date) * *
MM
/
DD
/
YYYY
I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing *
Required
I understand that there is no charge for my records to be sent electronically by secure email. However, I will be charged $15 for the first 10 pages and $.50 for each additional page if I request that my records be mailed to me or to someone else. *
Required
I understand that if I choose to have my records sent electronically via encrypted email, there is a risk that electronic communications may be compromised, unsecured, and/or accessed by a third party despite Creekside sending such records in a secure and encrypted format. If I chose this format, I acknowledge those associated risks. *
Required
By typing my name that indicates that I understand everything in which I have agreed to above *
A copy of your responses will be emailed to the address you provided.
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