Release Form for Medical Records Today's Date I authorize to release/send the following documents from your office (please check one or more boxes): Date of Birth 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: ($8.00 mailing fee) Van D. Merkle, DC, CCN, DCBCN, DABCI Andrew Dyer, DC, DABCA Natalie Yahle, DCTracey C. Barry MS 5777 Far Hill Ave Dayton, Ohio 45429 Phone:(937) 433-3241 Fax:(937) 496-5468 Email: mail@take2healthcare.com