Chart # Patient: Date Of Birth: By - Central Missouri Dermatology


Chart #____________________________
Patient: __________________________________
Date of Birth: _____________________________
By signing this form, I authorize medical test results to be given to the parties indicated below.
I understand that I may revoke this at any time by a written statement.
List person(s) to give test results to: _______________________________
______Do not give medical test results to anyone except me.
Primary phone number for test results: ______________________________________
Patient or Parent if minor: ________________________________________Date:____________


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