Medical Record Release - The Toledo Clinic

Patient First Name(Required)

Patient Last Name(Required)

Last 4 numbers of Social Security #

Maiden or Other Name

Patient Address(Required)

City(Required)

State(Required)

Zip Code(Required)

Date of Birth(Required)

Phone Number(Required)

Cell Number

Work number

I hereby authorize the below physician from The Toledo Clinic to release my medical records information.

Provider Name/Specialty:(Required)

Address

City

Zip Code

Phone