unique model of multidisciplinary practices under one roof

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Intake Form

Ocala's Top Chiropractor Office

Medical Records Release Form

By signing this form, I authorize you to release confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my protected health information to the physician/person/facility/entity listed above.

The information you may release subject to this signed release form is as follows:(Required)

Complete Records

History & Physical

Progress Notes

Care Plan

Lab Reports

Radiology Reports

Other

Release these records from:

Name

Address

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

Phone

To Be Faxed To:

Comments:

Patient Information

Signature of Patient(Required)

Patient Name

First Last

Patient Date of Birth

Date of Request(Required)

OCALA-BASED MEDICAL / CHIROPRACTIC OFFICE

Fakhoury Chiropractic Office has been serving Marion County over the years with a unique multi-disciplinary approach for treatment of musculo-skeletal pain such as headaches, neck pain, lower back pain, arm/leg pain and injuries from accidents

OCALA FL