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                              RECORD RELEASE AUTHORIZATION

DOCTOR / HOSPITAL ______________________________________________

ADDRESS _______________________________________________________

________________________________________________________________

________________________________________________________________

I HEREBY AUTHORIZE AND REQUEST THE RELEASE OF MY MEDICAL
RECORDS TO: 

         POTTSTOWN CHIROPRACTIC REHABILITATION CENTER

         8 GLOCKER WAY

         POTTSTOWN, PA  19465

         PHONE #610-718-1183               FAX #610-718-5512

THANK YOU IN ADVANCE FOR YOUR COOPERATION.

___________________________________________ ________________
Patient’s Signature / Date of Birth                                       Date

Patient’s Name (Please Print)

___________________________________________ __________________
If Patient Is A Minor Signature Of Parent Or Legal Guardian Relationship to Patient

___________________________________________ __________________
Witness To The Above Signatures Please Print Name