€¦ · *RELEASE OF MEDICAL RECORDS: I hereby authorize Dr. Aydin to release my medical...

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Transcript of €¦ · *RELEASE OF MEDICAL RECORDS: I hereby authorize Dr. Aydin to release my medical...

Page 1: €¦ · *RELEASE OF MEDICAL RECORDS: I hereby authorize Dr. Aydin to release my medical information to my insurance company if requested. Signature PATIENT IS A MINOR: I give permission
Page 2: €¦ · *RELEASE OF MEDICAL RECORDS: I hereby authorize Dr. Aydin to release my medical information to my insurance company if requested. Signature PATIENT IS A MINOR: I give permission
Page 3: €¦ · *RELEASE OF MEDICAL RECORDS: I hereby authorize Dr. Aydin to release my medical information to my insurance company if requested. Signature PATIENT IS A MINOR: I give permission
Page 4: €¦ · *RELEASE OF MEDICAL RECORDS: I hereby authorize Dr. Aydin to release my medical information to my insurance company if requested. Signature PATIENT IS A MINOR: I give permission
Page 5: €¦ · *RELEASE OF MEDICAL RECORDS: I hereby authorize Dr. Aydin to release my medical information to my insurance company if requested. Signature PATIENT IS A MINOR: I give permission
Page 6: €¦ · *RELEASE OF MEDICAL RECORDS: I hereby authorize Dr. Aydin to release my medical information to my insurance company if requested. Signature PATIENT IS A MINOR: I give permission
Page 7: €¦ · *RELEASE OF MEDICAL RECORDS: I hereby authorize Dr. Aydin to release my medical information to my insurance company if requested. Signature PATIENT IS A MINOR: I give permission