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One block East of Federal Hwy, directly across Target and the Coral Ridge Mall 2502 E. Oakland Park, Fort Lauderdale

Call / Text 954-564-2020
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Home » Patient Medical Release Form

Patient Medical Release Form

Records going to:

I hereby authorize and request you to release to:

Drs. John Bascome, Paul Klein, and Alyssa Panagos
2502 East Oakland Park Blvd
Fort Lauderdale, Fl 33306
PH: 954-564-2020 or Fax to us at: 954-565-4671 or Email to:

I would like my:(Required)
Patient Name(Required)
Patient Address(Required)
MM slash DD slash YYYY