ARROWHEAD DERMATOLOGY

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ARROWHEAD DERMATOLOGY . 7767 W. Deer Valley Rd. Ste #140* Peoria, AZ 85382* 623-487-3003*fax 623-487-0952. RECORDS RELEASE. PATIENT_________________________________ . PHONE # I authorize ARROWHEAD DERMATOLOGY to release my medical records to___________________________. Phone #_______________ Fax#________________. Address_________________________________ ___. ____________________________________. ________________________________________ ___. Signature Date ________________________________________ ___. Witness Date RECORDS RELEASE. PATIENT: ________________________DOB_________. PHONE #: _________________________________. I authorize Phone #: _______________ Fax #:______________. To release my medical records to: ARROWHEAD DERMATOLOGY . 7767 W. Deer Valley Rd Ste. 140. Peoria, AZ 85382. Phone: 623-487-3003*Fax: 623-487-0952. _____________________________________. Signature Date ________________________________________ ___________.

ARROWHEAD DERMATOLOGY . 7767 W. Deer Valley Rd. Ste #140* Peoria, AZ 85382* 623-487-3003*fax 623-487-0952 . RECORDS RELEASE . PATIENT_____ PHONE #_____D.O.B_____

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