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Women's Hormone Center of Northern
Virginia, PC
AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATIONPlease print___
Patient Another Last Names___
Date of birthstone NumberEmail Address___
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Schedule an appointment with a specialist at the women's hormone center.
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Women who are experiencing symptoms related to hormonal imbalances.
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The paperwork for the women's hormone center may require reporting on patient demographics, treatment methods, outcomes, and any adverse reactions.
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