Health Information Release Form | Metropolitan Pediatrics - Innovative Care for Infants, Children, and Adolescents

Release of Health Information

Please fill out the release of health information form below (for school/daycare purposes).

There is an administrative fee to complete the forms. We ask that you give us at up to 7 days, not counting the weekends or holidays, to complete any school, sports, or daycare forms. If you need it sooner, there will be an additional charge.

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

Release of Health Information

Information to be sent to:

Helpful Links

Additional Information

Office

Hours

Monday - Friday	8:30 AM — 5:00 PM
Saturday	8:30 AM — 1:00 PM
Sunday	Closed