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GLAMDERM A 130 E. 18th street Suite 1U NY NY 10003 P 212-674-0004 F 917-677-8525 E info glamderm.com W www. I also understand that in order to process this request to reproduce medical record information GlamDerm may charge a reasonable fee and/or utilize a photocopy service. I consent to disclosure of My HIV-related information as detailed above My non-HIV medical information as detailed above Both non-HIV medical and This authorization will automatically expire within six months from the...
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