Release of Information My Name First Last Who we may release information toI give Barrington Park Dermatological Associates, P.C. my permission to release biopsy results, blood work results, and any Medical or Billing information to the following person(s) on my behalf.NameRelationshipContact Number Patient Name First Last Patient Date of Birth MM slash DD slash YYYY Is patient under the age of 18? Yes No Name of Parent/Guardian First Last Primary Care DoctorPhoneThis field is for validation purposes and should be left unchanged.