Release of Records: Authorization for release of medical/dental information

I authorize the release of records to Or. Malekzadeh, including those that may contain confidential HIV/AIDS-related information, confidential communicable disease-related information, and information relating to mental health and/or alcohol/drug use. Please release the following records:
# Laboratory Reports
# Xray, MRI, Cat Scan Reports
# Progress Notes
# Medication List
# Complete Record
Signature *
You represent and warrant that the individual electronically agreeing to the terms of this Agreement is authorized and empowered to agree to this Agreement on your behalf. You further agree that checking a box to acknowledge your assent to this Agreement and/or clicking the "AGREE" button and/or performing any other similar electronic affirmation constitutes an electronic signature as defined by the Electronic
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