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MEDICAL RECORDS RELEASE FORM

REQUESTS THAT THE FOLLOWING MEDICAL RECORDS:
(PATIENT NAME HERE)

Lab (Blood/Urine)	X-Ray	ECG
Scans	Ultra Sounds	Other

BE RELEASED
TO:
(PRINT NAME HERE)

FROM:
PHYSICIAN'S NAME


ADDRESS


PHONE/FAX

PATIENT NAME	DATE OF BIRTH	SIGNATURE

 

WITNESS		DATE

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*This Consumer Information is provided by the David A. Edwards, MD, HMD, Bio Health Center and the International BioMedical Research Institute, a
501 ( c ) (3) tax exempt research foundation and has not been evaluated for content by the U.S.F.D.A., U.S.F.T.C., the Nevada State Homeopathic
Medical Board or the Nevada State Medical Board, but is the professional opinion of Dr. Edwards and the certified staff of Bio Health Center under their
interpretation of the First Amendment to the U. S. Constitution. Dr. Edwards is a licensed MD and a licensed Homeopathic MD in the State of Nevada.
The practice of Homeopathic Integrative medicine is licensed in Nevada and approved by the Nevada State legislature.