Release of Medical Records and X-Rays and Lab Work

I, the undersigned, do hereby give my permission to Dr. _____ and/or _____ (hospital or clinic) to release my medical records and/or X-Rays to Dr. Larry Schacht, P.O. Box 893, Georgetown, Guyana, South America.

Or

I, the undersigned, do hereby give my permission and authorize the following people to pick up my medical records and/or X-Rays so that they may be forwarded to me: Christine Kice, Phyllis Houston, Deborah Evans, Hattie Newell

Signed Malika Willis
Date _____

Originally posted on February 17th, 2013.

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