Clinical Professor of Medicine, University of Southern California
Office: 310-378-4059 Fax: 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 send them to Dr. Dollinger