Medical & Cosmetic Records Release Form

To (Your Current Physician's Name):*
Address:*
Phone:*
Fax:
Patient Name:*
Patient Date of Birth:*
MM slash DD slash YYYY
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
If "Other" is selected, please elaborate here:
I HEREBY AUTHORIZE THE RELEASE OF MY MEDICAL AND/OR COSMETIC RECORDS TO SUNEEL CHILUKURI, MD. SEND APPROVED RECORDS TO:
SUNEEL CHILUKURI, MD
5427 BISSONNET STREET, SUITE 500
HOUSTON, TX 77081
Signature of Patient/Guarantor*
Date*
MM slash DD slash YYYY
Printed Name of Signed Patient/Guarantor*
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I HEREBY AUTHORIZE THE RELEASE OF MY MEDICAL AND/OR COSMETIC RECORDS TO SUNEEL CHILUKURI, MD. SEND APPROVED RECORDS TO: