Vermont Natural Family Medicine PLC

Patient date of birth: *

MM

DD

YYYY

Information will be released to the following physician at:

Vermont Natural Family Medicine 346 Shelburne Road, Suite 402. Burlington, VT 05401 (802) 238-8603

Dr. Joshua Green, N.D.

The information will be used on my behalf for the following purpose: *

Sharing of Medical Records

Transfer of Care

By checking the boxes below, I specifically authorize the release of the following medical records, if such records exist: *

All hospital records

Medical records needed for continuity of care

Most recent five year history

Laboratory reports

Pathology reports

Diagnostic imagine reports

Clinician office chart notes

Physical therapy records

Mental health records

Emergency and urgent care records

Billing statements

Please send the entire medical record

Date *

MM

DD

YYYY