Release of Records TO Family Vision Solutions Patient Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY TO: Add RemoveFAX:PLEASE RELEASE COPIES OF THE FOLLOWING RECORDS PER MY REQUEST:(Required) Complete eye care records Current exam and prescription(s) Current prescription(s) only SignatureSigned By Patient/self Guardian Date(Required)I hereby request the release of records to the person listed. Parent Guardian SignatureDate(Required)Please send the above information at your earliest convenience. FAX TO: (713) 349-9834 THANK YOU FOR YOUR PROMPT ATTTENTION Δ
