releaseofinformation by WT9OlU41

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									                          Roberto Lipsztein, MD
                           Jack F. Dalton, MD
                         Reuven Z. Grossman, MD
                       Corporate Park Radiation Oncology
                              1000 South Avenue
                        Staten Island, New York 10314




             CONSENT FOR RELEASE OF MEDICAL RECORDS


Please release the records of _________________________________________

Address: ________________________________________________________

Date of Birth: _________________________

To: _______________________________, MD



Authorized Signature: ____________________________________________

Date: _____________________________

    Pathology Slides-Dates: _______________

    Port Films

    ___________________________________________

    ___________________________________________

    ___________________________________________

								
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