MEDICAL RECORDS RELEASE

Please list all physicians and treatment centers that we will need to contact

_____________________________________________________________________________________

I hereby authorize and request you to release to

Dr. Carlos Ramos

c/o Gar Hildenbrand

Gerson Research Organization

7807 Artesian Road

San Diego CA 92127-2117

Fax: 858-759-2502

all records in your possession concerning my illness and/or treatment during the period

from:_______________________ until:_______________________

dates

________________________________________________________/_________________________________________________

Your name (please print)/Witness signature

___________________________________________________

Your date of birth

A photographic copy of this authorization shall be as valid as the original