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AUTHORIZATION TO RELEASE RECORDS

By signing this document you authorize the following party or entity to release written records pertaining to the care and treatment of the named patient. Written records will be sent by mail or fax.
Doctor’s Name:
Address
Patient:
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Records to be released to:






Name: Denise E. Smith, O.D., Allison Orr, O.D.
Company: The Center for Vision Development, P.A.
Address :5656 Bee Cave RoadBuilding D, Suite 201Austin, TX 78746
Phone: 512.329.8900
FAX:512.329.8105
Website:www.visiontherapyaustin.com
Email:info@cvdaustin.com
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