Atlanta Riverdale | Medical Release – Dominion Orthopaedic & Spine

Medical Release Authorization

You are authorized and directed to furnish any and all information requested pertaining to my medical care and treatment to:

Dominion Orthopaedic Clinic, LLC
John I. Foster, III, M.D., FACS
William G. Sutlive, III, M.D.
Nicole E. Forsythe, M.D.

5555 Peachtree Dunwoody Road
Suite 215
Atlanta, GA 30342
Phone: (770)455-4009
Fax: (770)455-4065

This authorization includes furnishing of the originals or copies of all charts, summaries, test results and all other written memoranda or data including x-rays and photographs.

Date Of Birth*

Signature*

Todays Date*