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Get Pact Record Release Authorization and Pregnancy Verification

S in the presence of your doctor or clinic. Return one copy to Pact, keep one for your records and leave one for your clinic or doctor. This form allows us to talk to your clinic or doctor about the medical aspects of the pregnancy and/or the medical condition of your child. Patient’s Name Doctor’s Name Address Telephone Contact person Clinic Name Address Telephone Contact person Hospital Name Address Telephone Contact person Proof of Pregnancy Date this form was completed Pregnancy has be.

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How to fill out and sign Pregnancy california verification online?

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