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Medical Record Release from 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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By signing this I authorize TLC Pediatrics of Amarillo to release the Medical Records (Protected Health Information on the above named child(ren). This Protected Health Information is to the sent to:

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