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Medical Records Request
Authorization for Release of Information
First name
(Required)
Last name
(Required)
Birthday
(Required)
Month
Best Contact Number
(Required)
Email
(Required)
Person / Organization to receive records:
(Required)
Self / Authorized Representative
Clinic
If "Self" was selected above, how do you want to receive the records?
(Required)
Pick up at clinic
Email
N/A
Signature
(Required)
Clear
Print Name
(Required)
Relation to patient:
Self
Parent / Legal Guardian
Spouse
Other
Submit
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