AUTHORIZATION TO RELEASE RECORDS FROM CVD

Denise E. Smith, OD
Olivia Browne, OD
The Center for Vision Development, P.A.
5656 Bee Cave Road
Building D, Suite 201
Austin, TX 78746

512.329.8900 (Phone)
512.329.8105 (FAX)
www.visiontherapyaustin.com (Website)

By signing this document you authorize The Center for Vision Development, P.A. to release written records pertaining to the care and treatment of the named patient. Written records will be sent by mail or fax.

Patient Name:

First Last

Date of Birth:

Records to be released to:

Name:

Company:

Address

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

Phone(Required)

FAX(Required)

Patient or Parent Printed Name

Patient or Parent Signature

Date of Signature