AUTHORIZATION OF RELEASE

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AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

I hereby request and authorize the release of all information, without limitations regarding any physical and mental condition, as revealed by your observation or treatment, past, present or future.

This includes medical, surgical and dental history, x-ray findings, diagnosis, prognosis and access to all hospital records and photocopies of the same.

I request that you release the above information to:
Address
Certification of Signature
Please sign your name either using your fingers for touch devices or using your mouse.
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Certification of Witness Signature
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