Peninsula Doctor Medical Release

Please correct the errors described below.

By signing the form below, I authorize the release of my medical records to Peninsula Doctor.

I hereby authorize (name of your current medical practice)

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To release copies of my medical records to be sent to:

Peninsula Doctor
Attn: Dr. Kroes & Dr. Hiroshima
401 Burgess Dr. Suite D, Menlo Park, CA 94025
Phone 650.800.3365
Fax 650.252.0043 (Do not fax more than 15 pages)

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