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Get Northlake Ob Gyn

Date of Birth: By signing this form, I authorize Northlake Obstetrics & Gynecology, P.A. to (check one): Release my confidential medical record to the entity listed below. Name: Street: City: State: Phone # Zip: Fax # The information will be used or disclosed for the following purpose: My authorization extends or is limited to: All records of my visits from.

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