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1775 Williston Road, Ste 110 South Burlington, VT 05403 pH (802) 7351252 Fax (802) 8629637 AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION Patient Full Name: DOB: Current Address/City/State/Zip: List
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Start with the patient's personal information, including their full name, contact details, date of birth, and social security number if required.
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Include a section for the patient to provide information about their current symptoms or complaints, including the date of onset and any associated factors.
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