Neuropathy & Neurotherapy Center of Dallas

MEDICAL RECORDS REQUEST

PATIENT'S NAME: *

SOCIAL SECURITY NO: *

DATE OF BIRTH: *

REQUEST FROM (PATIENT'S DOCTOR OR HOSPOTAL):

NAME: *

ADDRESS: *

CITY: *

STATE: *

ZIP: *

PHONE: *

FAX: *

I HEREBY AUTHORIZE THE ABOVED NAME TO RELEASE ANY AND ALL MEDICAL RECORDS, INCLUDING ANY TETS, MIRs, AND X-RAYS TO:

NEUROPATHY & NEUROTHERAPY CENTER OF DALLAS

12870 Hillcrest Rd, Suite 201

Dallas, TX 75230

PATIENT'S SIGNATURE: *

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DATE: * +

Neuropathy & Neurotherapy Center of Dallas

12870 Hillcrest Rd, Suite 201, Dallas, TX 75230 (972) 991-6731