Release of Medical Information

Release of Medical Information

  • Release of Medical Information
  • Name of Doctor/Therapist or Pain Specialist above and their Address Below
  • To Release My Health Information to the Office of:

    Portland Ketamine Clinic
    Dr. Enrique Abreu, Dr. Danyi

    Phone: (503) 207-4992
    Fax: (503) 961-1859
  • Type NA if not applicable
  • Signature
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.