testing 20 June Step 4admin2023-06-21T12:15:38+00:00 RELEASE OF INFORMATIONPatient Name Date of Birth MM slash DD slash YYYY Please list the names of any family members, friends or any other person that we may release information to, such as: general medical condition including treatment, prescriptions to be picked up at our office if you were unable to come by, medical records, school notes, etc. Please note: for children under the age of 18- to the parent filling out patient paperwork, please list the second parent on this form if they will need access to the patient’s information.Name Name Name Name Name Name Signature Date MM slash DD slash YYYY
