Patient Document Upload

Please upload any necessary documentation.

Name(Required)

First Last

Date of Birth:(Required)

File(Required)

Max. file size: 50 MB.

Comments

Signature(Required)

By uploading files through this form, I acknowledge that I am voluntarily providing my medical information to Shane Retina for the purposes of treatment, care coordination, or scheduling. I understand that the information I submit may include protected health information (PHI), and I consent to its use and disclosure as permitted under HIPAA.

Date(Required)