Medical Information & Purchase Release on Patient's Behalf
Please fill out this form to authorize the release of medical information, in-office purchases, and communication with RevolutionaryMD staff to the person(s) indicated below on your behalf.
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Patient Full Name
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First Name
Last Name
Full Name(s) of Authorized Personnel
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By signing below, you are authorizing the release of your medical information, in-office purchases, and communication with RevolutionaryMD staff on your behalf to the indicated personnel above.
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