REQUEST FOR RELEASE OF MEDICAL RECORDS

Date: ________________________

To:

________________________________________

^{Name of Physician or Hospital}

________________________________________

^Address

________________________________________

^{CityStateZip Code}

I hereby request that my complete medical records, operative reports, pathology reports, x-ray reports and laboratory data will be released to Thomas Janicki, MD

Thomas I. Janicki, M.D.

EndometriosisUSA.com

1611 South Green Road

Cleveland, OH 44121

Phone: 800-891-5285

Fax: 216-381-5975

Name: _________________________________________________

^{LastFirst               Middle}

Address: _______________________________________________

^{Number and Street}

_______________________________________________

^{CityStateZip Code}

Home Phone: ________________________________________

Date of Birth: ________________________________________

^MonthDayYear

____________________________________________

^{Patient Signature}