Release of Records

Release of Records
East Vancouver Eye Clinic

Dr. Gary Cole & Dr. Tracy Dodd

6680 NE 159th Ave STE 102, Vancouver, WA 98682

P: 360-449-3937

F: 360-449-3094
Today's Date*

MonthDayYear
Date
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth

MonthDayYear
Date
Please list the names and birth-dates for ALL children/dependents with records to transfer:
*If requesting for multiple adults, please fill out 1 form per individual*
I would like to...*

transfer records from prior office TO East Vancouver Eyetransfer FROM East Vancouver Eye to a new office
Please provide us with the NAME of the office we are contacting:*
Please provide the contact information for the office we will be reaching out to: *
Doctor Name:

Address 1:
Address 2:
City/State/Zip:

Office Phone: 
Office Fax:
Office Email:
If you are leaving our practice, please tell us why.
Consent to retrieve or forward your information: *

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