Medical Records Release Form

Request and Release of Medical Records

To Whom it May Concern

Please release the medical records of the following patient to St Lawrence Optometry via fax to 613-549-4510 or email to info@slvision.ca - Patient Name:

First Last

DOB:

Health Card #:

Previous Optometrist/Ophthalmologist:

First Last

Phone:

Fax:

Email:

Signature:

Medical Records Release Form

Request and Release of Medical Records

St Lawrence Optometry East

St Lawrence Optometry Downtown