Release of Information | Flaheartvascular.com

Release of Information

First name

Last name

Phone

Date of Upcoming Service

Month

Day

Year

Do we have person to leave a voicemail regarding your appointment at the phone number provided?

Yes

Do we have permission to text this phone number appointment reminders?

Yes

Release of Information

Below, I have listed the names of anyone that I have authorized to have access to my personal health information.

If there are no one to release information to, please select the Not Applicable selection button.

Not Applicable

Name of Person (First & Last Name)

Relationship

Phone

By signing below you agree you have reviewed the documents and understands the information provided for each.

Patient Name

Patient Signature

Signature field is empty.

Date and time

Month

Day

Year

Time

HoursMinutes

Phone

Florida Heart & Vascular Surgery Center