km c284e-20171004080722 · 2017. 10. 4. · treatments. i also authorize the release of any medical...

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Page 1: KM C284e-20171004080722 · 2017. 10. 4. · treatments. I also authorize the release of any medical information and/or reports related to my treatment to any federal, state or accreditation
Page 2: KM C284e-20171004080722 · 2017. 10. 4. · treatments. I also authorize the release of any medical information and/or reports related to my treatment to any federal, state or accreditation
Page 3: KM C284e-20171004080722 · 2017. 10. 4. · treatments. I also authorize the release of any medical information and/or reports related to my treatment to any federal, state or accreditation
Page 4: KM C284e-20171004080722 · 2017. 10. 4. · treatments. I also authorize the release of any medical information and/or reports related to my treatment to any federal, state or accreditation
Page 5: KM C284e-20171004080722 · 2017. 10. 4. · treatments. I also authorize the release of any medical information and/or reports related to my treatment to any federal, state or accreditation
Page 6: KM C284e-20171004080722 · 2017. 10. 4. · treatments. I also authorize the release of any medical information and/or reports related to my treatment to any federal, state or accreditation
Page 7: KM C284e-20171004080722 · 2017. 10. 4. · treatments. I also authorize the release of any medical information and/or reports related to my treatment to any federal, state or accreditation
Page 8: KM C284e-20171004080722 · 2017. 10. 4. · treatments. I also authorize the release of any medical information and/or reports related to my treatment to any federal, state or accreditation