Records Release Form
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1Records Release Form
I, ____________________________________ do hereby authorize the release of my child’s/children’s
medical records from:
_________________________________________
_________________________________________
to the Chippenham Pediatric and Adolescent Medicine location circled below:
(Parents, please circle the location most convenient for your family.)
Harbour Pointe Office
Old Jahnke Road Office
6510 Harbour View Court, Suite 100
7023 Old Jahnke Road
Midlothian, VA 23112
Richmond, VA 23225
Child’s Name: ___________________________________________ Birth Date: ____________________
Other Children:
Name: __________________________________________ Birth Date: ____________________
Name: __________________________________________ Birth Date: ____________________
Name: __________________________________________ Birth Date: ____________________
Name: __________________________________________ Birth Date: ____________________
Mother’s Name: _____________________________ Father’s Name: _____________________________
Signature:
_________________________________________
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