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The pdf version can be downloaded here.

Authorization for Release of Information

I hereby authorize Dr. F. Tuna Burgut to contact and obtain and/or provide my medical history and other related information to/from the following individuals/institutions for the purpose of medical care, which can include information such as labwork, psychological testing, medical and psychiatric history, treatment history, and written medical records:

I understand that this correspondence may involve a conversation or a transfer of written material and that I have the right to revoke the above authorization at any time.

Thanks for submitting!

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