Authorization for Release of Information

"*" indicates required fields

Patient Full Name*

If patient is a minor, parent/guardian name.*

I do hereby authorize Mobile Quick Care & DOT, LLC. of 1101 Durant Rd Brandon, FL 33511, to obtain my medical records from:

Name Of Medical Practice

Address

Street Address Address Line 2 City State ZIP Code

Phone Number*

Fax

Patient (or Parent/Guardian) Printed Name

Patient Date Of Birth

MM/DD/YYYY

Patient (or Parent/Guardian) Signature

This field is for validation purposes and should be left unchanged.

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