Medical Records Release Form
Eye Consultants of Colorado
10791 Kitty Drive; Suite B
Conifer, CO 8033
This patient has come to our office for their eye care and vision needs. At the
patients request, please forward all of their medical records, including a complete
contact lens prescription (if relevant) to our office.
This patient is transferring their care to your office for their eye care and vision
needs. At the patients request, their medical records are being transferred to your
We are specifically requesting the following information regarding
this patient. Please forward the requested information at your earliest convenience.
I hereby grant the above named person(s)/medical facility permission to exchange
information from my records.