Record Release Form


For Patients leaving our Practice in order that their records are forwarded to their future Doctor.

Please click on the text above and print out the form. It can be mailed or faxed to the office or it can be dropped off.

There is a $25 fee for forwarding complete records to another office. This is due before the records are sent. It can be paid by cash, check, or credit card.

Patient Survey

Our office has changed to a web based Patient Survey for our Current Patients to provide our office with valuable insight into how our office can better serve them.

If you are a current patient, we ask that you click the button below to access our Patient Survey.

All answers are anonymous and will only be used for office improvement purposes.

Thank you for taking a few minutes to help us serve you better!

Welcome to Clifford Family Practice, please send a message below and someone will get back to you shortly, Thanks!