Medical Release form - Thrive Comprehensive Medical Group

THRIVE COMPREHENSIVE MEDICAL GROUP

18607 Ventura Blvd, Suite 102 Tarzana CA 91356

Phone: 8186001472

Fax: 8186001494

Is this an Urgent request?

First Name

Last Name

Date of birth

Phone/Mobile

Enter information pertaining to the facility that currently has your medical information.

Name of the facility

Doctor's Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Facility FAX number

Facility phone number

Your Message

Signature

Sign Here

File Upload

Choose File