Candace McDaniel, DO, MRO
drcmcdaniel@sbcglobal.net
Phone: (214) 727-6390


Authorization and Consent to Release Medical Records

From: Dr. Candace McDaniel

Please send the following records marked with a check mark (√):

_____ History & Physical Exams

_____ Physicians Orders

_____ Dosing Records

_____ Urine Drug Screens

_____ Counseling Progress Notes

_____ Medication Flowsheet (Rx’s)

_____ Labwork (CBC, CMP, RPR, SML’s)

_____ TB test dates


(Ex) Patient Signature: ____________________________________     

Print Name: __________________________________________           

Date: ______________________________________________             

Send Records to:

Name of Person/Center: ___________________________________     

Address: _______________________________________________                                                                                                                                _______________________________________________      

Phone: ________________________   Fax: ___________________     

Email: _________________________________________________