Petoskey Gynecology & Infertility
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Medical Record Release
Record Release Form
Patient First and Last Name:
(Required)
Date of Birth:
(Required)
I consent to release my medical records from Clare Heidtke and Petoskey Gynecology and Infertility, and IVF Michigan to:
Provider Name:
(Required)
Provider Office:
(Required)
Office Phone Number:
(Required)
Date of Appointment
MM slash DD slash YYYY
Office Address:
Office Fax Number:
Electronic Patient Signature
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Your name in above box will serve as your signature.
Date
(Required)
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.