Medical Records Release Form

Medical Records Release Form:

I ______________________________ request that my medical

record to include only the last two office visits, skin test results,

spirometry, recent X-rays, and vaccine sheet (if pertinent), be sent

to:

Advanced Allergy and Asthma of Virginia

Barry K. Feinstein, M.D.

5924 Harbour Park Drive

Midlothian, Virginia 23112

Fax Number: (804) 739-9006

Patient Date of Birth: ______________________________________

Signature: _________________________________________________

Date:_____________________________________________________

Email address (optional) : ___________________________________

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Parent category: Legal