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RECORDS Patient’s Name: ________________________________ Date of Birth: ________________________ Address: _________________________________ Day Phone: ________________________ _________________________________ Email: I request that all medical records of the patient Send all medical records to: Me at same address/email as above My new healthcare provider below named above to be released from: Vein Clinic PA 7810 Terrey Pine Court Eden Prairie, MN 55347 ________________________ Name.

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