Please download, print and complete the Medical Records Release Form prior to coming to our office. Faxing or carrying your patient forms with you to your appointment will, minimize your time spent in our waiting room.
Print this page Release of Medical Records PDF (20 kb)
Glaucoma Associates of Texas
RELEASE OF MEDICAL RECORDS To: _______________________________________
From: ____________________________________ (Patient’s name)
This is to request that you release copies of the above named patient’s medical records, registration forms, correspondence and materials pertinent to the patient’s care. Include chart dictation, procedure notes, flow sheets, GDx, OCT, VF, ORB, photographs, past medication and allergies.
Please send this information to:
Glaucoma Associates of Texas 10740 N. Central Expwy. Suite 300
Dallas, Tx. 75231
Signed:_________________________________________ (Signature of patient or person responsible for patient)
__________________________________________ Relationship
Date: __________________________________________
10740 N. CENTRAL EXPRESSWAY SUITE 300 DALLAS, TX 75231
(214) 360-0000 (800) 683-0386 FAX (214)360-0083
417 W. MAGNOLIA AVENUE FORT WORTH, TX 76104
(817) 923-2000 FAX (817) 923-6639
WWW.GLAUCOMAASSOCIATES.COM
Testimonials