Release of Records
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 Eye
transfer 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:
Address 1: Address 2: City/State/Zip: Office Phone: Office Email:
If you are leaving our practice, please tell us why.
Consent to retrieve or forward your information:
Should be Empty: