Online Form Submission

Please complete this online form to request a copy of your medical records, to request your medical records be SENT to another provider or to request your medical records FROM an outside  provider’s office.  Please include complete address, phone and FAX numbers to ensure accurate delivery. To begin click the picture below.


Authorization for Release of Medical Information

Authorization for Release
of Medical Information


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Coastal Skin Surgery and Dermatology

Visit our office today to find out how we can assist you with any medical, surgical, and/or cosmetic dermatology needs.