Cardiology Associates of Boca Raton
DATE: ___________________TO:______________________________________________________I HEREBY AUTHORIZE AND REQUEST YOU TO RELEASE TO: David Funt, M.D. Jay Baker, M.D. Constance Fields, M.D. Steven M. Coletti, M.D. Ronald Gabor, M.D.The complete history in your possession concerning my care and / or treatment during the period from: ________________________________________________.Name: _________________________________Date of Birth:______________Address:_____________________________________________________________ _____________________________________________________________Signature: ___________________________Witness:________________________IF RELATIVE, PLEASE STATE RELATIONSHIP:_______________________________If you have any questions feel free to contact our medical records office at 591-483-8335.Thank you, Custodian Medical Records ................
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