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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

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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
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
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
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

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