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SHCSStaff:___
Page1of2PATIENTNAME___
Student ID#___UniversityofCalifornia, Davis
StudentHealthandCounselingServices
ReleaseofInformationDepartment
OneShieldsAvenue, Davis,CA95616Phone(530)7526129Fax(530)7525587Birthdate:___Phone:___AUTHORIZATIONFORRELEASEOFHEALTH
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