If Barbara Nylander, what year was your last appointment? Year
Release records to: ALL INFORMATION MUST BE COMPLETED
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Records are not kept on site. We ask for 90 days to obtain your records from storage, copy and mail/fax. There will be a $30 fee for copying and transferring records. This must be paid prior to records being pulled. This can be paid by cash in the office or by credit card.
Name on card: Year Card Number: Card Number EXP Date:EXP Date CCV: CCVSignature for Payment: Signature