Medical Release Form Template

This medical release form template has a simple purpose, to give consent that the patient’s information can be released by their healthcare provider to someone other than the patient.

Check out the template below:

Form Preview

Use This Template

MEDICAL RECORDS INFORMATION

Physician/Clinic's Name
1. YOUR AGREEMENT

By agreeing to this release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box.

PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.

Customize the Medical Release Form

The beauty of all WPForms templates is that they’re easy to use and fully customizable. This means you can quickly adapt this form to fit your needs.

We’ve added a signature field to the form so you can collect paperless information from patients.

You could add a section to include details for another patient, for example, if a parent or guardian fills out the form on behalf of a minor. Consider adding a Multiple Choice form field to ask the user the reason for the authorization. Finally, there’s the option to add a field stating when the authorization will end, saving you and the patient valuable time.

Use This Template