Medical Release Form - Adult

Dear Doctor ___________________________,

I give my voluntary, informed, consent to you to release my child’s medical records and information, including all test results, images and associated reports to PXE International. They are conducting research on pseudoxanthoma elasticum (PXE). Information contained in my child’s medical records may be of value for their study. This is not a request for any additional medical tests. Please file this consent in my child’s record, in the event that any of the researchers contact you to release my child’s information.

If you have digital copies of the records, please email them to Erin Oliphant at eoliphant@pxe.org, or fax them to 202.966.8553, attention: Erin Oliphant.

Sincerely, _________________________________

Signature Date Request for medical records for ____________________________________ (Print full name)

Date of Birth: _______________

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