Have Your Records Sent to RidgeView

S. Matthew Buchanan OD PC
8540 Scarborough Dr
Colorado Springs, CO, 80920

Secure email:

Fax

Full Name

First Last

I authorize the above-named provider/entity to release the following designated medical information.

Information to be Released

Copy of complete medical records including results of diagnostic testing

Copy of contact lens prescription

Copy of spectacle lens prescription

Insurance information

Other

Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Fax

I, authorize the release of my eye exam records to be released to:

Dr. S. Matthew Buchanan at RidgeView Optometry 8540 Scarborough Dr. Ste 240, Colorado Springs, CO 80920

Please fax my records to (719) 282-3081.

If you have any questions, please call (719) 495-5904. Thank you

Patient's Printed Name

First Last

Patients Date of Birth

Patient/Guardian Signature

Today's Date

Eye Emergency