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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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