Medical Release Form

"*" indicates required fields

Patient Name*

First Last

Last 4 Digits of SSN*

Patient Address*

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

Date of Birth*

Phone*

Request Date*

Clinician/Physician Name*

Group Practice Name

Group Practice Address*

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

Date of Service*

Specify items requested*

Slides

Report(s)

Tissue (research)

Slide Number(s)

Tissue (Research)

Fresh

Not Fresh

(Above requires approval from Institutional Review Board or IRB)

If fresh, specify specimen site

How would you prefer the materials be delivered?*

Fax

Mail

Other

(Above requires approval from Institutional Review Board or IRB)

Fax

Address

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

If you are a patient requesting materials, a copy of your photo ID is required.

Max. file size: 64 MB.

If you are a patient designee or patient representative, notarization is required.

Max. file size: 64 MB.

Patient Signature

Date

Requesting Designee Signature

Date