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9094 E. Mineral Ave. Suite #120 Centennial, CO 80112 Phone: (303× 7795437 Fax: (303× 6899628 www.pediatrics5280.com Patients 18 Years or Older Release of Health Information Name: Date of Birth:
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Gather all necessary personal information from the patient such as their full name, date of birth, address, and contact details.
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