Medical Records Release Form

I grant permission to release a copy of my medical records to SAMUELSON EYECARE.

In initiating this request, I hereby release my practitioner from any laws governing the disclosure of confidential or privileged information.

Please enter all of the necessary information below and click “Submit”:

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Name of office where previous eye exam was held.
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.