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Faith Pediatrics Medical Records Form

Patient Information (Please indicate in the comment box if the child is a Newborn - 5 month.)

1st Child's Name

1st Child's Date Of Birth

2nd Child's Name

2nd Child's Date Of Birth

3rd Child's Name

3rd Child's Date Of Birth

4th Child's Name

4th Child's Date Of Birth

Parent/Legal Guardian Name

I am requesting that Faith Pediatrics & Adolescent release the medical records of the above mentioned patients records to the following email address.

*Email

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