Information Release Form (Optional)Information Release Form (Optional) Patient’s Name*Birth Date* MM slash DD slash YYYY I request and hereby authorize Rock Therapeutic Services to* Receive Releasehealthcare information of the patient named above from/to*This request and authorization applies to* Healthcare information relating to the following treatment, condition, or dates All healthcare information OtherIf patient is a minor (17 or younger), Patient or Guardian's name*Signature*Patient’s Name (if 18 or older) or Guardian’s Name (if patient is 17 or younger)** by checking this box and typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature.Date* MM slash DD slash YYYY
