Medical Release Form

If you think your old records will be important in our decisions, then the only way to guarantee we receive your records in a timely manner is if you physically obtain them from your other physician yourself and bring to your clinic visit with us. PLEASE SEND THIS COMPLETED FORM DIRECTLY TO THE OTHER PHYSICIANS, NOT TO OUR OFFICE as we will not fax for you unless you are in our office. Note, if a fax request is sent to another physician then we usually do not receive this information from your other physician for at least 4-6 weeks.

• NEW PATIENTS

1. If you are a new patient and have been referred to our practice then no forms are needed please ask your referring doctor to send your medical records.

2. If you are a new patient who is self referred you will need to contact previous doctors who records might be relevant to your appointment with us and have them fax your records to 713-795-0855

• ESTABLISHED PATIENTS

1. If you are a established patient wanting to send your medical records that you have with us to another doctor please fill out the "MEDICAL RELEASE TO" form located above.

2. If you are a established patient and you are wanting your records from another doctor sent to us please fill out the "MEDICAL RELEASE FROM" form located above.