BLOG for Msgr. Leo

       

St. Philip Catholic Church

St. Joseph Catholic Church


                  

                      

                  

                      

                      

               

 

 

 

 

RECORDS RELEASE AUTHORIZATION

 

 

 

Name of Previous Doctor or Clinic

 

City/State:

 

I hearby authorize and request you to release my complete history records in your posession, concerning my illness and/or treatment to:

 

Dr. Michelle T. Valella

Optometrist

485 E. Columbia Ave.

Battle Creek, MI  49014

(269) 963-4405

(269) 963-3111 fax

office@CanYouSeeClearly.com

www.CanYouSeeClearly.com

 

Name of Patient: Birth Date:

Address:

 YES, I am requesting this release on the following date:

      OR

 There are NO previous records to release.