Colorado Medical Records Release Form 3
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Medical Records Release Form
To: _____________________

Eye Consultants of Colorado

________________________

10791 Kitty Drive; Suite B

________________________

Conifer, CO 8033
Fax: 303.816.7218

Patient Name:

_____________________________________________

DOB: _____/_____/_____

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
office.

□ Note:

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.
________________________
Signed

____