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6131 Luther Lane Suite 216 Dallas Texas 75225 Phone 214-987-2020 Fax 214-739-3725 Authorization for Fagadau Hawk Swanson M. D. to RECEIVE the medical record information of Patient Name D. O. B. Phone Patient s Address I authorize Fagadau Hawk Swanson M. D. LLP to RECEIVE my health records from Doctor/Company Address Phone Fax Complete record Records of care from the following dates to Records concerning the following conditions Other please specify The reasons or purposes for this release of...
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