Clinical Professor of Medicine, University of Southern California
| 927 Deep Valley Drive #170 Rolling Hills Estates, CA 90274 |
Office: (310) 375-4349 Fax: (310) 310-791-0969 |
Medical Release Form
Date_____________ To: (facility)____________________________________
Please release to Malin Dollinger, M.D. the following medical records or other materials:
- Medical records and reports
- Pathology report
- Operative report
- Discharge summary
- Consultations
- Pathology slides
- X-ray/ CT/ MRI/ ultrasound films/ scans and images
- Blood tests
- Other medical information________________________________
__________________________________________________________________________
Patient or authorized representative
_____________________
Date
Please deliver these materials to me or my representative,______________________
so I may hand-carry them to Dr. Dollinger
Return to the Information Forms for The Second Opinion Consultation