Records Request

Instructions: Download and complete the release of information form and mail it to us. It must be signed and dated by the patient or legal guardian. In the "who is requesting records section" complete the information for one only please, either Courtney Bolluyt, PA-C, your new dermatologist or yourself.

If you are requesting records come to you, copies will be sent by US postal service; please enclose a self-addressed stamped envelope with extra postage. We will send a surgical summary free of charge.

Release of Patient Information Form