File Release Form

Name: Lindsay Optometry
Address: 28 Cambridge St S, Lindsay, ON, K9V 3B6, CA
Telephone: 705-878-5738
Price range: $000 - $300

Today's Date*
Date Format: MM slash DD slash YYYY
Name
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
From : Clinic name or Doctor's name*
Clinic Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Clinic Phone Number
Consent*
I hereby consent to have my files released to Lindsay Optometry.
Signature
Please fax files to 705.201.0179 or email to lindsayoptometryoffice@gmail.com

Please fax files to 705.201.0179 or email to lindsayoptometryoffice@gmail.com