Sharman Family Clinic by UpAhK8Gj

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									                                  Sharman Family Clinic
                                      P.O. Box 1260
                              Dripping Springs, Texas 78620
                          (512) 858-2997 ph (512) 858-2987 fax




_______________________________________                                ______________________
Patient Name                                                               Date of Birth


I, ______________________________________ authorize Sharman Family Clinic staff to leave

personal medical information on my; Home phone __________________


                                        Cell Phone ___________________


                                        Work phone __________________

I realize that the information could be any of the following; lab results, X-Ray results,
prescription medication information and/or messages regarding my medical care.

								
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