Transfer Medical Records

In preparation for your appointment with us, please complete the online form below, “Forward Records to Advanced Vision Therapy Center”. Click submit, and we'll take care of the rest.

*Note: All fields marked with an asterisk (*) are required.

I hereby authorize the release of my medical and/or optical records and request that they be transferred from:

My personal health information, and complete medical records may be released to the Doctors affiliated with:

This records release is valid for 1 (one) year from the date of signing. This records request is for the purpose of continuation of care. Advanced Vision Therapy Center is not liable for any fees associated with the release of the requested information. The patient bears that liability, and requests to be notified in advance of any charges for the release of PHI and/or medical records.

The purpose of this release is to obtain:

Complete Medical/optical RecordsContact Lens PrescriptionEyeglass PrescriptionOther