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PLEASE PRINT CLEARLY HEALTH RECORDS OF: LAST NAME FIRST NAME STREET, APT#, P.O. BOX, R.R.# MIDDLE NAME CITY / TOWN Miss/Ms/Mrs/Mr/Other PROVINCE / COUNTRY POSTAL CODE CONTACT INFORMATION DAY PHONE NO. ALTERNATE PHONE NO. ( ( ) E-MAIL ADDRESS ) DETAILS OF REQUESTED INFORMATION Please describe the records you are requesting. Be as specific as possible as this will assist the request process. Attach a separate sheet if this space is not sufficient: REPORT TYPE: LAB.

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