mitchellderm.com - Permission to Release Information

Mitchell Dermatology
815 Commerce Drive
Perrysburg, Ohio 43551
419.872.HOPE (4673)
Fax: 419.873.8329

PERMISSION TO RELEASE INFORMATION

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Patient Name *

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I hereby give my permission for my medical records to be released by Mitchell Dermatology and forwarded to

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I hereby give my permission for my medical records to be forwarded to Mitchell Dermatology from:

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