Consent for Release of Records

I hereby request and authorize Barry-Eaton District Health Department to release my medical records and/or information including: *

I hereby request and authorize Barry-Eaton District Health Department to release my medical records and/or information including: Immunizations WIC Hearing/Vision Lead Other Other
Patient Name Patient Name * First Last
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Date of Birth Date of Birth * / MM / DD YYYY
Phone Phone * - ### - ### ####
Please complete this section if record is to be released to another agency:
Practice Name
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Fax Fax - ### - ### ####
This section MUST be filled out by anyone completing the form. Please sign in the appropriate box!
Patient Signature *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date * / MM / DD YYYY
Parent/Legal Guardian Signature if patient is under 18 years of age

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Parent/Legal Guardian Printed Name
Date Date / MM / DD YYYY