PH
843.837.4400 |
FAX
843.837.4440
BLUFFTON
350 FORDING ISLAND RD, STE 100 | BLUFFTON, SC 29910
HILTON HEAD ISLAND
25 HOSPITAL CENTER COMMONS, STE 200 | HILTON HEAD, SC 29926
PORT ROYAL
1813 RICHMOND AVE | PORT ROYAL, SC 29935
Medical Records Release
I authorize May River Dermatology, LLC to
Receive medical records
Send medical records
Medical Records received from:
Doctor/Medical Practice Name
*
Fax
*
Phone
*
Medical Records sent to:
Doctor/Medical Practice Name
*
Fax
*
Phone
*
Patient Name:
*
Patient Phone Number w/Area Code:
*
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
*