Release Form for Medical Records


I authorize to release/send the following documents from your office (please check one or more boxes):

All Documentation, Testing, Notes and Recommendations
Blood Test Results
Hair Analysis Results
Urinalysis Results
Toxic Urine Results
Stool Test Results
Doctor’s Notes and Test Analyses
Vitamin Recommendations
Chiropractic Treatment Notes
Acupuncture Treatment Notes
Thermography Evaluations
Thermography Images
NeoControl Treatment Logs

Please fax the above information to:

Please mail the above information to:

 
Van D. Merkle, DC, CCN, DCBCN, DABCI
Andrew Dyer, DC, DABCA
Natalie Yahle, DC
Ashley Marchek, DC, FIAMA
Tracey C. Merkle, MS
5777 Far Hill Ave
Dayton, Ohio 45429
Phone:(937) 433-3241
Fax:(937) 496-5468
Email: mail@take2healthcare.com