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  • Records Release Form

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    Alexander Scott
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    Records Release Durham NC 27713. I hereby authorize the release of my records or copies of such and request that they be transferred to or from: jamel Mcduffie, dds, PA Family Dentist 6104 Fayetteville road, Suite 107 Durham, North Carolina 27713 phone: (919) 484-7478 fax: (919) 572-9942 Alexander scott.

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    Original Title

    Records Release Form[1]

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    Records Release Durham NC 27713. I hereby authorize the release of my records or copies of such and request that they be transferred to or from: jamel Mcduffie, dds, PA Family Dentist 6104 Fayetteville road, Suite 107 Durham, North Carolina 27713 phone: (919) 484-7478 fax: (919) 572-9942 Alexander scott.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    2 views1 page

    Records Release Form

    Uploaded by

    Alexander Scott
    Records Release Durham NC 27713. I hereby authorize the release of my records or copies of such and request that they be transferred to or from: jamel Mcduffie, dds, PA Family Dentist 6104 Fayetteville road, Suite 107 Durham, North Carolina 27713 phone: (919) 484-7478 fax: (919) 572-9942 Alexander scott.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 1

    Jamel McDuffie, DDS, PA

    6104 Fayetteville Road, Suite 107


    Durham, North Carolina 27713
    Phone: (919) 484-7478 Fax: (919) 572-9942
    *************************************************************

    Records Release

    Dr. Velma E. Cooper, D.M.D. PA


    To_______________________________________________________
    (Doctor/Hospital)
    6104 Fayetteville Steet #106
    Address___________________________________________________

    Durham
    NC
    27713
    City____________________
    State _________________
    Zip_________
    E-Mail Address_____________________________________________
    I hereby authorize the release of my records or copies of such and request
    that they be transferred to or from:
    Jamel McDuffie, DDS, PA
    Family Dentist
    6104 Fayetteville Road, Suite 107
    Durham, North Carolina 27713
    Phone: (919) 484-7478 Fax: (919) 572-9942

    Alexander S. Scott
    _____________________________________________________________
    Print Name of Patient

    A. Scott
    03/19/2013
    _______________________________________________________________________
    Digitally signed by A. Scott
    DN: cn=A. Scott, o, ou, email=alexandersscott@gmail.com, c=US
    Date: 2013.03.19 12:47:41 -04'00'

    Patients Signature

    Date

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