Records Request Form

Name: Parkland Eye & Vision
Address: 223 140th St S, Ste 500, Tacoma, WA, 98444, US
Telephone: 253-537-7544
Price range: $000 - $300

Provider/Entity

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

Patient Full Name

First Last

I authorize the above-named provider/entity to release the following designated medical information.

Copy of complete medical records including results of diagnostic testing

Copy of contact lens prescription

Copy of spectacle lens prescription

Other information

Parkland Eye & Vision Clinic, PLLC
223 140th ST S Suite 500
Tacoma, Washington, 98444
Phone: 253-537-7544
FAX: 253-535-4888

Consent(Required)

I HAVE READ AND UNDERSTAND THIS FORM. I VOLUNTARILY AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM.

Signature

Patient or legally authorized individual signature

Date

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