6470 East Johns Crossing, Suite 200
Johns Creek, GA 30097
Ph 470.282.5729 | Fax 770.674.5795
Dr. Herbert Alexander | Dr. Paola Bonaccorsi | Dr. Dale Sarradet
Medical Records Release
I authorize May River Dermatology, LLC to
Receive medical records
Send medical records
Medical Records received from:
Doctor/Medical Practice Name
*
Address
Phone
Medical Records sent to:
Doctor/Medical Practice Name
*
Fax
Phone
Patient Name:
*
DOB:
*
I request a copy or summary of the following medical records:
Complete Medical Record
Biopsy Report(s)
Lab Report(s)
Medication Allergies
Allergy Test/Treatment
Surgical Procedures
Other:
Please check one:
For dates of service from
to
For all dates of service
Additional Comments:
Date
*
:
Patient/Parent/Guardian Signature
*