Georgia Medical Records Release Form 3
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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 records i