Medical release form - Chesapeake Public Schools 2026

1. Click ‘Get Form’ to open the Medical release form in the editor.
2. Begin by entering the date at the top of the form. This helps track when the request is made.
3. In the section labeled 'Name of Prior Facility', input the name of the medical facility where previous mammogram films were taken.
4. Next, provide the complete address of that facility, including city, state, and zip code.
5. Fill in the phone number and fax number for the prior facility to ensure smooth communication.
6. Enter the patient's name, social security number (SS#), and date of birth in their respective fields.
7. Finally, sign and date at the bottom of the form to authorize the release of records. Ensure all information is accurate before submission.

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