File Release Form

Release File Consent Form

Today's Date*
MM slash DD slash YYYY
Name
First Last
Date of Birth*
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