Designated Party Release Form

This information will be sent to your provider and will be kept as part of your patient records.

First Name: *

Last Name: *

Email Address *

Date of Birth: *

Address (Please indicate City, State, Zip):

Home Phone:

Mobile phone number:

Work Phone:

If we are unable to contact you by phone regarding your labs, xrays ect. may we leave a message on your answering machine/ voicemail on the above listed numbers?

Yes

No

Please list below the appropriate individuals with whom we may leave medical information regarding your health.

Phone Number:

Relationship to Patient:

Name:

Phone Number:

Relationship to Patient:

Primary Care Provider (Doctor) to release information to:

Name:

Address (Please indicate City, State, Zip):

Phone Number

Fax:

Date

Signature: *

Use your mouse or finger to sign in the box below.

Triad Primary Care

Triad Primary Care