Information release form
Patient’s Name (*)

Please let us know your name.
DOB

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I request and hereby authorize Rock Therapeutic Services to (*)

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healthcare information of the patient named above from/to (*)

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This request and authorization applies to (*)




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Parent/Guardian/Patient Name (*)

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Patient’s Name (*)

Please write a subject for your message.

by checking this box and typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature.

Date (*)

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