Medical Records Release Form

Medical records are stored for 10 years after graduation.

Full Name  
Cell phone number  
Graduation year/ Last year as an employee.  
Full name while attending Wofford  
Date of Birth  
Current Student
I request that a copy of the following information contained in my medical record to be:
Please check records to be released or obtained

I wish to exclude the release of theses items and confirmation pertaining to:
An unaltered photocopy of this document may be accepeted in lieu of the original and I understand that the original will be maintained in my records.