Record Release WCC Address

DR. ELIZABETH HOEFER, DC, DCCJP

25909 Pala Ste. 190

MISSION VIEJO, CA 92691

949-359-8385

Record Release Request

Full Name *

Date *

I hereby authorize

Name: Well Connected Chiropractic

Address: 25909 Pala Ste. 190

City: Mission Viejo State: CA Zip Code: 92691

To release information regarding the following (Please check all boxes that apply)

To:

First Name *

Last Name *

Address *

Phone *

City *

State *

Email

Taking x-rays/imaging *

Yes

No

If yes, please complete the following in its entirety.

If no, please disregard the following.

I am taking into my possession my x-rays/imaging. I realize that I cannot receive treatment without my x-rays/imaging, as they are necessary to provide chiropractic care. I release Well Connected Chiropractic from the responsibility of maintaining my x-ray/imaging records.

I understand that there is a $15 shipping fee for my imaging that will be paid over the phone with a credit card before the imaging will be mailed. If the shipping fee exceeds $15, I will be responsible to pay the difference.

Address to send records to:

Signature *

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