Department Of Public Health Petition Form Page 3

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Department of Public Health
3
Petition Form
Names of any prior and/or subsequent treating practitioners:
Name:
Telephone:
Address:
Name:
Telephone:
Address:
Name:
Telephone:
Address:
Witnesses:
Full Name:
Telephone:
Address:
Full Name:
Telephone:
Address:
Attach copies of any supporting documents, such as photographs, records, correspondence etc.
Fill out the attached Consent for Release of Medical Records.
Sign and date below. Signature must be notarized.
____________________________________
Dated this
day of
20
Petitioner’s Signature
Signed and sworn before me this
day of
20
.
____________________________________
Notary Public
Commissioner of Superior Court

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