Consent of Release of Medical Records to Monroe Optical Inc.

Monroe Optical Inc.

1751 N MAIN STREET, FRANKLIN, INDIANA 46131

PHONE: 317-736-8958

NATIONAL TOLL-FREE No: 1-800-999-1522

TOLL FREE FAX: 1-800-888-4760

EMAIL: monroeoptical@hotmail.com

Release of Medical Records to: Monroe Optical Inc

Physician Name or Office *

Physician Phone Number *

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Patient Name *

Patient Email *

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Consent of Release

*I DO HEREBY AUTHORIZE THE RELEASE OF MY MEDICAL RECORDS TO: MONROE OPTICAL INC. BY SELECTING "I AGREE" CHECK BOX, I AM SIGNING THIS DOCUMENT ELECTRONICALLY. I AGREE THAT MY ELECTRONIC SIGNATURE IS THE LEGAL EQUIVALENT OF MY MANUAL/HANDWRITTEN SIGNATURE ON THIS DOCUMENT.

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I Agree

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