Free Medical Release Form 28
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www.womenscareonline.com (770) 622-9810
COMPLETE WOMEN'S HEALTHCARE
Dori Kasparek, M.D.
6325 West Johns Crossing
Ste. 202
Duluth, Georgia 30097
770-622-9810
770-622-9811
MEDICAL RECORDS RELEASE FORM
Patient’s
Name:______________________________________________________________________
Social Security #:
___________________________________________________________________________
Date of Birth:
______________________________________________________________________________
Please release my medical records from the following physician(s):
Name:
______________________________________________________________________________
Address:
______________________________________________________________________________
City, State,
Zip:__________________________________________________________________________
Phone #:
______________________________________________________________________________
Fax #:
______________________________________________________________________________
The release of my re