Release of Medical Records

For the specified patient above, I hereby request and authorize the release of all medical records including operative reports, consultation reports, office notes, imaging studies, photographs, discharge summaries, or any other necessary clinical information to and/or from the following physician:

Dallas W. Homas, MD, PLLC
7902 Jones Maltsberger Rd.
San Antonio, TX 78216
Phone: 210-640-6310
Fax: 210-824-2183

(Please Sign Below)