Fredrick H. Creutzmann, M.D.

4323 North Josey Lane, Suite 203

Carrollton, Texas 75010

Office Phone - 972-394-7277

Fax Number - 972-394-4800

 

  

To: ____________________________________________________

 

________________________________________________________

 

________________________________________________________

 

________________________________________________________

 

 

I authorize and request the release of all my medical records to:

 

Fredrick H. Creutzmann, M.D.

4323 North Josey Lane, Suite 203

Carrollton, Texas 75010

 

 

My Name: _______________________________________________

 

 

Social Security# _______________________ Birthday: ____/____/____

 

 

Address: ________________________________________________

 

 

City: _____________________ State: ______ Zip Code: ___________

 

 

 

 

 

Patient Signature: _________________________ Date: ____/____/____

 

 

Witness Signature: ________________________ Date: ____/____/____