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RECORD RELEASE FORM

I, _____________________________________________________________, give permission for the medical records of the patient(s) listed below to be transferred to the office of Dr. Thomas Binder at:

Hartford Area Pediatrics
43 West Main Street
Avon, CT 06001
ph. (860) 678-9400
fax (860) 678-9480

Patient Name _____________________________________________________ DOB: _________________

Patient Name _____________________________________________________ DOB: _________________

Patient Name _____________________________________________________ DOB: _________________

Patient Name _____________________________________________________ DOB: _________________

Patient Name _____________________________________________________ DOB: _________________

Signed __________________________________________________________ Date _______________