AUTHORIZATION TO RELEASE RECORDS

By signing this document you authorize the following party or entity to release written records pertaining to the care and treatment of the named patient. Written records will be sent by mail or fax.

Doctor’s Name:

First Last

Address

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

Phone(Required)

FAX(Required)

Patient:

First Last

Date of Birth:

Records to be released to:

Name:	Denise E. Smith, O.D., Olivia Browne, O.D.
Company:	The Center for Vision Development, P.A.
Address :	5656 Bee Cave RoadBuilding D, Suite 201Austin, TX 78746
Phone:	512.329.8900
FAX:	512.329.8105
Website:	www.visiontherapyaustin.com
Email:	info@cvdaustin.com

Patient or Parent Signature

Date of Signature

The Center for Vision Development

The Center for Vision Development