Health Information Release Form

Email:*

Please enter your contact email for this request
Parent's Name*
First Last
Information to be released:*
Patient's Name*
First Last
Birth Date*
MM slash DD slash YYYY
Release Information to:
- Myself
- School
- Physician / Practice
- Attorney
School Information
Physician / Practice's Information
Attorney's Name
Reason for Leaving*
Information to be sent to:
Fax
Address*
Street Address Address Line 2 City State ZIP Code