Form Download this form Request for Medical Records From (Name of Doctor)*: Doctor's Address*: Doctor's City*: Doctor's State*: Doctor's Zipcode*: Doctor's Phone/Fax: Patient Name*: Date of Birth*: Address 1*: Address 2: City*: State*: Zipcode*: Your Email*: I HEREBY AUTHORIZE RELEASE OF REQUESTED INFORMATION TO REBECCA M. JONES, MD, AT 138 ELLIOT STREET, BRATTLEBORO, VT 05301 Signature*: Date*: [recaptcha] This authorization is valid for 90 days and may be revoked at any time prior to.