Consent to Release Medical Records

CONSENT TO RELEASE MEDICAL RECORDS

Student Name(Required)

First Last

Date of Birth(Required)

Student ID Number

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Immunization Information(Required)

Immunization Records with laboratory reports if applicable

Other

Immunization Records with laboratory reports if applicable

Please Check One:(Required)

Mail To: Address As Above

Mail To Different Address

Fax

Pick Up in the Health & Wellness Center

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Attention (Mail to Different Address)

First Last

Name of School or Agency(Fax)

Fax Number

Attention (Fax)

First Last

CAPTCHA

Signature(Required)

Date(Required)