Patient Name(Required)

First Last

Date of Birth(Required)

Patient Email(Required)

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Contact Phone Number(Required)

Information Processing

Information To Be Transfered(Required)

Most Recent Exam

All Clinical Medical Records

Other

Medical Release(Required)

This medical record may contain information about physical or sexual abuse, alcoholism, druge abuse, sexually transmitted diseases, abortion, or mental health treatment. Seperate consent must be given before this information can be released.

I consent to have the above information released

I DO NOT consent to have the above information released.

HIV Release(Required)

This medical record may contain information concerning HIV testing and/or AIDS diagnosis or treatment. Seperate consent must be given before this information can be released.

I consent to have the above information released

I DO NOT consent to have the above information released.

Records Processing

Healthcare Provider or Facility Name(Required)

Provide the name of the healthcare provider or facility name to coordinate records with.

Authorization(Required)

I agree and authorize Laser Eye Institute to release my medical records.

I understand that this authorization is valid for a 15-day period from the date that is signed. I may revoke this consent at any time through written notice. Fees are assessed in accordance with State of Michigan Medical Record Access Act. I understand that Laser Eye Institute has the right to refuse to copy medical records until fees are paid.

Patient Signature(Required)

Records Transfer

Information Processing

Records Processing