Medical and Cosmetic Records Release

Name: Refresh Dermatology
Address: 5427 Bissonnet St #500, Houston, TX, 77081, United States
Telephone: 7133326984

First Name

Last Name

To:

Address:

Street Address City State ZIP Code

Phone:

Fax:

Patient Name:

Patient Date of Birth:

Please release the following medical and/or cosmetic records (Check all that apply):

All medical and cosmetic records and photos (digital and print)

Progress notes

Operative notes

Pathology results

Other

Date