Medical Record Release

Patient First and Last Name:(Required)

Date of Birth:(Required)

I consent to release my medical records from Clare Heidtke and Petoskey Gynecology and Infertility, and IVF Michigan to:

Provider Name:(Required)

Provider Office:(Required)

Office Phone Number:(Required)

Date of Appointment

Office Address:

Office Fax Number:

Electronic Patient Signature(Required)

Your name in above box will serve as your signature.

Date(Required)

Phone

This field is for validation purposes and should be left unchanged.