Patient Demographics - Third Street Family Health Services 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's full name in the designated fields for Last, First, and Middle names. Ensure accuracy as this information is crucial for identification.
3. Fill in the date of birth using the provided format. This helps verify the patient's identity and age.
4. Complete the patient’s street address, city, state, and zip code to ensure proper communication and record keeping.
5. Select the release destination by checking either Akron Campus or Mahoning Valley Campus, and provide their respective addresses.
6. Indicate who is requesting the records by checking all applicable boxes such as Patient/Parent/Legal Guardian or Doctor/Hospital.
7. Specify the purpose of release by checking relevant options like Patient Care or Insurance. This clarifies why records are needed.
8. Sign and date at the bottom of the form to authorize the release of medical records. Ensure that a witness also signs if required.

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