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Medical Record Release to TLC Pediatrics

3501 Soncy Road, Suite 102
Amarillo, Texas 79119
Tel: 806-353-7900
Fax 806-353-8321
tlcofamarillo.com
Where Compassion, Caring and Dedication Come First

"Where Compassion, Caring and Dedication Come First"

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I Authorize the release of medical Records to : TLC Pediatrics of Amarillo 3501 Soncy Road Suite 102 Amarillo, Texas 79119 ATTENTION: Dr. Maaytah

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Clear Signature
Patient if over 18 years old
Note : you can fill out and save the form as well by downloading after submitting