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Medical Release Form
Today's Date
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I hereby authorize:
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To release any information including the test results, diagnosis and records of any treatment or examination rendered to me to:
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Specific Request
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Patient
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Date of Birth
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Signature
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Date
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Office Phone
610-374-8133
1200 Broadcasting Road, Suite 200
Wyomissing, PA 19610
We’re welcoming new patients
and can’t wait to meet you.
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