Peninsula Gastroenterology Medical Group, Gastroenterologists logo for print
Peninsula Gastroenterology Medical Group, Gastroenterologists
Redwood City: 2900 Whipple Ave | Suite 245 |Redwood City, CA 94062 • Phone: 650-365-3700
Mountain View: 2500 Hospital Drive | Building 8, Suite B | Mountain View, CA 94040 • Phone: 650-964-3636
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Patient Release Form

First Name
Last Name
Date of Birth
Today's Date

Dear Patient,
This form is required to release any of your medical information to your spouse, family, friends, physicians, attorneys, etc. Please complete at least one person or specify "None". Please note: if you state "None", we CANNOT release ANY information to anyone.

Relatives
Name:
Date of Birth:
Name:
Date of Birth:
Name:
Date of Birth:
Name:
Date of Birth:
Physicians
Name:
Name:
Name:
Name:
Other People
Name:
Date of Birth:
Name:
Date of Birth:
Name:
Date of Birth:
Name:
Date of Birth:
Communications

Please Indicate how you wish us to reach you:

1st Phone # Preference:
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2nd Phone # Preference:
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Acknowledgement

This release of information form will be in effect until notified of the contrary. If you want this form to expire on a particular date, indicate here.

Date of Expiration:

I hereby give permission for representatives of Peninsula Gastroenterology Medical Group to release or discuss Protected Health Information (PHI) with the stated individuals on this form (listed above).


Atherton Endoscopy Center photo

Atherton Endoscopy Center

While you are a patient at Atherton Endoscopy Center, our highly competent and professional staff will care for you. Everyone from the receptionist to the physician embraces our philosophy of patient-focused care. Above all, our staff is friendly and concerned for your comfort.