Patient Forms

Medical Records Request

Authorize the release of your medical records to Elite Sports Medicine, Attn: Dr. Marc Matarazzo.

For your privacy, this form is not submitted online. Complete it here and print it to bring to your appointment, or simply complete it at our office — our team will be glad to help. Please do not email completed medical forms. Questions? Call 561-202-8886.

Patient Information

First Name

Last Name

Date of Birth

Phone Number

Email Address

Alt Phone

Address

City / State / Zip

Release Records From

Name of the provider or facility currently holding your records.

Provider or Facility

Send Records To

Elite Sports Medicine

Attn: Dr. Marc Matarazzo
11380 Prosperity Farms Rd, Ste 204
Palm Beach Gardens, FL 33410
Phone / Fax: 561-202-8886

Information to Be Released

Complete Medical Records

Imaging / Radiology Reports

Progress Notes / Office Visits

Lab Reports

Other

Patient Signature (type full name)

Date

Printed Name

If signed by someone other than the patient, relationship

Witness Signature (optional)

Witness Date