Consent Form | Ann Arbor, MI | Ganger Dermatology

Ganger DermatologyConsent to Release Medical Information or Records

I hereby Authorize(Required)

Name of sending person, agency or institution

Patient Name(Required)

To release to Ganger Dermatology, information pertaining to the care and treatment of:

First Last

Patient Date of Birth(Required)

Patient Phone(Required)

Patient Address(Required)

Street Address Address Line 2 City State ZIP Code

Consented Reports/information

This authorization is valid from the date of signing unless revoked in writing by the undersigned

Signature(Required)

Signature of patient, or legal guardian signature

Printed Name(Required)

Name of the above signature

First Last

Patient outside records are processed in our Ann Arbor location. Please mail to the following address:

1979 Huron Parkway Ann Arbor, MI 48104