Authorization For Release of Records
Patient Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Family Members
First Name
Last Name
First Name
Last Name
First Name
Last Name
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Next
Previous Clinic Name
*
Previous Clinic Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Previous Clinic Email
example@example.com
Previous Clinic Phone Number
*
-
Area Code
Phone Number
Signature (please use your finger or mouse)
*
Submit
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