Patient Name * Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Social Security Number * Social Security Number, no dashes, just the last 4 numbers please Name patient hereby requests and authorize Name of Individual or Organization Address To release copies of my complete medical records and any and all orther information regarding my diagnosis testing and / or treatment that is maintained by licensee for whom the complaint is files against to WEST VIRGINA BOARD OF OPTOMETRY, 172 Summers Street, Charleston, WV 25301. I understand that this authorization may be revoked at any time, except to the extent action has been taken prior to revocation. This consent will expire in sixy (60) days after the date signed below or sonner at my election. I acknowledge that I have read and understand theis authoriziation as it applies to me. Signature * Agree By clicking agree this acts as your signature CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit