POB 5005
Ashland, Virginia 23005
Phone:804-752-3041 Fax: 804-752-3776
AUTHORIZATION TO RELEASE IMMUNIZATION RECORDS
Patient’s Name: Date of Birth:
Previous Name: R-MC Graduation Year:
I authorize the Randolph-Macon Health Center to release my Immunization Records to my current address:
Name:
Address:
City: State: Zip Code:
If you transferred in or out of R-MC, please indicate the year you transferred AND your expected year of
graduation.
Transfer Year: Expected Graduation Year:
Please include a phone number in the event we need to contact you about your records:
Patient Signature: Date Signed:
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