c1-preview.prosites.comc1-preview.prosites.com/38754/wy/docs/NewPatientForms.pdf · FORT MYERS, FL...
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![Page 1: c1-preview.prosites.comc1-preview.prosites.com/38754/wy/docs/NewPatientForms.pdf · FORT MYERS, FL 33907 (239) 936-0181 RELEASE OF RECORDS I hereby authorize the office ofDr. Scott](https://reader033.fdocuments.in/reader033/viewer/2022060304/5f09062d7e708231d424dda4/html5/thumbnails/1.jpg)
![Page 2: c1-preview.prosites.comc1-preview.prosites.com/38754/wy/docs/NewPatientForms.pdf · FORT MYERS, FL 33907 (239) 936-0181 RELEASE OF RECORDS I hereby authorize the office ofDr. Scott](https://reader033.fdocuments.in/reader033/viewer/2022060304/5f09062d7e708231d424dda4/html5/thumbnails/2.jpg)
![Page 3: c1-preview.prosites.comc1-preview.prosites.com/38754/wy/docs/NewPatientForms.pdf · FORT MYERS, FL 33907 (239) 936-0181 RELEASE OF RECORDS I hereby authorize the office ofDr. Scott](https://reader033.fdocuments.in/reader033/viewer/2022060304/5f09062d7e708231d424dda4/html5/thumbnails/3.jpg)
![Page 4: c1-preview.prosites.comc1-preview.prosites.com/38754/wy/docs/NewPatientForms.pdf · FORT MYERS, FL 33907 (239) 936-0181 RELEASE OF RECORDS I hereby authorize the office ofDr. Scott](https://reader033.fdocuments.in/reader033/viewer/2022060304/5f09062d7e708231d424dda4/html5/thumbnails/4.jpg)