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14300 W. Granite Valley Drive, Ste D20Sun City West, AZ 85375P: (623)2257164 F: (623)2302086Medical Records Release AuthorizationPatient Name:___ Birth date___Patient Address___City___State___Zip___Phone___Please check all information to be released:___ Entire record___ Laboratory results___ Imaging reports___ Office visit notes___ Prenatal Records___ Operative notes___ Other______ Dates of treatment ___Please release records to:Northwest Women's Career

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