Records Release Form

Pupila Family Eye & Ear Care
12512 Memorial Dr | SuiteA, Houston, TX 77024
P: 713-324-8889
F: 713-324-8909

"*" indicates required fields

Patient Name*

First Last

Date of Birth*

Address*

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

Phone*

to release confidential health information about me, by releasing a copy of my medical records(including exam history and all imaging), and, if available, a summary of my protected health information to the facility listed below:

Facility:*

Address:*

Phone:*

Fax:*

Patient Signature*

Date*

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Records Release Form

Energy Corridor

Lantern Lane

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Energy Corridor

Lantern Lane

Pasadena

Sealy

New Caney