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  • * Any items marked with a red asterisk must be filled out, but any other items may be skipped.

  • I hereby authorize Dr. Azrin, Dr. Millsaps, or Leslie Kahn to obtain and to release my information to the following people, doctors, or facilities:

  • DO NOT LIST YOUR OWN NAME BELOW. 

    PLEASE LIST DOCTORS, HOSPITALS, AND FAMILY, YOU WOULD LIKE ME TO OBTAIN INFORMATION FROM AND RELEASE INFORMATION TO.

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    ** If you enter your e-mail address, be sure to type your e-mail address twice below, just to confirm that we have the right e-mail address.


  • If you would like to pay any past or upcoming copays, but don't know the amount, please call 205-329-7815 from 8am-noon or from 1pm-4pm to find out what you owe.

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