top of page

Arizona Vision
Therapy Center

HOME
ABOUT US
WHAT WE TREAT
SERVICES
PATIENT RESOURCES
PROFESSIONAL RESOURCES
QUIZZES
BLOG
MORE

Use tab to navigate through the menu items.

Visualize a

healthier future.

Healthcare Release Form

If you have any questions, please call us at 520-886-8800.

Authorization to Release Healthcare Information

Patient Name:

Patient Name *

Date of Birth:

Date of Birth*

Provider Name:

Provider name: *

Address:

Address

Phone:

Phone*

Fax:

Phone*

I give permission to release my requested healthcare information to Arizona Vision Therapy Center.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Please fax records to 520-886-8805 as soon as possible.

Call and schedule an appointment today!
Phone: 520-886-8800

Fax: 520-886-8805

E-Mail: visiontherapy@live.com

2312 N Rosemont Blvd

#100 & #103

Tucson, AZ 85712

T: 9:00am-5:00pm (Closed for lunch 1:00pm-2:00pm)

W: 9:00am-5:00pm (Closed for lunch 1:00pm-2:00pm)

Th: 9:00am-5:00pm (Closed for lunch 1:00pm-2:00pm)

F: 9:00am-5:00pm (Closed for lunch 1:00pm-2:00pm)

S: 8:00am-2:00pm

bottom of page