"*" indicates required fields

Medical Records Release Authorization
Address (Doctor or Hospital)*
THEREBY AUTHORIZE AND REQUEST YOU TO RELEASE TO:

Dr. David B. Tuchinsky D.C., PLLC 105 Mariner
Health Way, Suite 208 St.
Augustine, Fl 32086

Fax 904-460-2903
THE COMPLETE HISTORY RECORDS IN YOUR POSSESSION CONCERNING MY ILLNESS AND OR TREATMENT DURING THE PERIOD:
Your Name*
Address*
MM slash DD slash YYYY
I have read and understand the above.