Records Release Form

  • AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
  • Date Format: MM slash DD slash YYYY
  • I hereby request and authorize records to be sent to / requested from:
    Fusion Medical Aesthetics / Dr. Lisa Gardner
    7250 Hawkins View Drive, Suite 411
    Fort Worth, Texas 76132
    Phone: (817)644-1758
    Fax: (817)644-3112
  • Sexually Transmitted Disease (STD) as define by law, RCW70.24 et.seq., including herpes, herpes simplex, human papilloma virus, wart, condyloma, chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lympogranuloma venereuem, HIV, AIDS, and gonorrhea.
  • authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.
  • authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above.
  • Date Format: MM slash DD slash YYYY