LAKE POINTE PEDIATRIC ASSOCIATES,P.A.
6900 Scenic Drive Suite 103 Rowlett TX 75033 Telephone 972-412-1034 Fax 972-475-5708
Date: ______________________________
To: __________________________________________________________________________
Address_______________________________________________________________________
City________________________________________________ State ________ Zip __________
Telephone: ____________________________ Fax: _________________________________
I ________________________________, hereby authorize Lake Pointe Pediatric
Associates, P.A. to obtain copies of my medical records pertaining to my diagnosis and
treatment. Including communicable diseases such as Human Immunodediciency
Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS); drug and alcohol
use testing information, laboratory test results, medical history, psychiatric treatment
or any other such related information.
Please release patient information to
Lake Point Pediatric Associates
Pamela M.M. Wieland, M.D.
Dynal M. London, M.D.
6900 Scenic Dr.
Suite 103
Rowlett TX 75088
Patient Name:
_______________________________________________________
Patient Address:
_______________________________________________________
_______________________________________________________
DOB:
_______________
Social Security Number:________________________________
Patient Signature ______________________________________________ Date __________
(Parent or legal guardian if patient is a minor)
The confidentiality of these records is protected by federal and other laws and is
intended to be delivered to the individual/s mentioned above. If you received this
information in error, please contact our office immediately for instructions on
returning these documents. 972-412-1034
Revised 6.25.02