Release of Information | drkarinmd

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Please complete the below document to provide the contact information of any providers you wish to share information with Dr. Varblow.

Authorization for the Release of Information

Patient's Name (First, MI, Last)*

Provider Name

Provider Email

Provider's Phone

Expiration Date (Optional)

Signature

Date

Dr. Karin Varblow, MD

1489 Chain Bridge Rd, #203

McLean, VA 22101

Ph/Fax: 703-996-4737

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