CONSENT TO RELEASE INFORMATION

_____________________________________________________________________ Last First MI Suffix (Jr., Sr.) DOB (mo/day/year)

For the purpose of continuing medical care, the individual identified above (or guardian) authorizes the release of information to: John P. Chesson, M.D., P.C. 1104 Amherst St., Suite 204 Winchester, VA 22601 (540) 678-3867 (540) 678-1440 FAX Thank you for providing: NOTES

Progress Notes (office notes, History and Physical)

LABS

Urinalysis (UA dipstick, micro) Urine cultures Serum chemistries (i.e. chem-8, basic metabolic panel, comprehensive metabolic panel, etc.) CBC (blood counts, H&H) PSA (please send all available PSA results) 24 hour urine collections (creatinine clearance, urine protein)

IMAGING

CT abdomen/pelvis MRI abdomen/pelvis Ultrasound (retroperitoneal, abdominal, kidney)

_____________________________________________________________________ Patient Signature Date

_____________________________________________________________________ Guardian Date

CONFIDENTIALITY NOTICE: The documents accompanying this facsimile are confidential and belong to the sender who is legally privileged. The information is solely for the use of the individual or entity named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or use of the contents of this facsimile information is strictly prohibited. If you have received this facsimile in error, please immediately notify the office by telephone (540) 678-3867 to arrange for the return of the document to this office.

consent to release information

Patient Signature. Date ... CONFIDENTIALITY NOTICE: The documents accompanying this facsimile are ... to arrange for the return of the document to this office.

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