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Medical Release

MEDICAL RECORDS INFORMATION

Physician/Clinic's Name
1. YOUR AGREEMENT

By agreeing to this release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box.

PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.

Contact

  • 941-271-7575

  • 941-894-0402
  • blondellpt@gmail.com
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