School Medical Records Release Form
Student Name:
Date of Birth:
Student ID (if applicable):
Parent/Guardian Name:
Relationship to Student:
Phone Number:
Email Address:
School Name:
School Address:
School Phone Number:
Release Records To:
Recipient Address:
Recipient Phone Number:
Recipient Email (if applicable):
Type of Medical Records to be Released:
Immunization Records
Physical Examination
Allergy Information
Health History
Other
Purpose of Release:
Authorization:
I authorize the release of the medical records as described above.
Signature:
Date: