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Transfer of Records


Please be aware that this form is not encrypted (secure) and not intended to send Private Health Information.

First and Last Name:
Street Address:
City:
State:
Zip Code:
Phone Number:
Email:
Patient's Name(s):


Send Records To:
Name:
 
Street Address:
City:
State:
ZIP:
Phone Number:
Email:
 
Comments/Questions:

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