• Authorization for McLean Dermatology and Skincare Center to Obtain Medical Information from another Facility

  • Patient Information

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  • Individual or Organization to which McLean Dermatology will Release Records

    The above-mentioned patient or his/her parent/legal guardian authorizes McLean Dermatology and Skincare Center, located at 6849 Old Dominion Drive, Suite 450, McLean, VA 22101, to obtain medical record information from the following individual or facility:
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  • Should be Empty: