Release of Information Request

Midwest Alternative Treatment Clinic, PC Release of Information Request
I, first, last name request and allow Dr David Manno and Midwest
Alternative Treatment Clinic, PC to release my medical records to office name*.

I understand that these records include my mental health information as well as history of my ketamine infusion therapy.
Date*

MonthDayYear
Date
Patient Name*

First NameLast Name
Patient Signature*
Email
example@example.com
Should be Empty:

Midwest Alternative Treatment Clinic, PC Release of Information Request