Johns Creek Vickery Village | 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 Eric S. Steenlage 5830 Bond Street Suite 200 Cumming, Ga. 30040 P. (770) 455-4009 F. (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.
Patient Name*
Patient Signature*
Date Of Birth*
Today's Date*