Fillable Online tribeca pediatrics form Fax Email Print

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Click ‘Get Form’ to open it in the editor.
Begin by entering the name of your child or children in the designated field. Ensure that you provide accurate spelling for proper identification.
Next, fill in the date of birth for each child listed. This information is crucial for the medical records release.
In the authorization section, read through the disclosure statement carefully. Confirm your understanding and then proceed to sign as the parent or guardian authorizing the release.
Indicate your relationship to the child or children in the provided field to clarify your authority over this request.
Finally, if you wish to receive a copy of the records, remember to include a self-addressed manila envelope with your submission.

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