I, the undersigned and being a parent, guardian, or otherwise due authorized caretaker, authorize release of the entire medical record of the above named patient to Kidology Pediatrics, PLLC for the purposes of medical care. I request that those records be released in CCDA format and submitted to Kidology Pediatrics, PLLC via via encrypted email to info@kidologypeds.net or Fax to our office at 248-918-2609
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