Release Form Other

RE: Release of medical records for patient:

To release a copy of all medical records related to my treatment rendered from the period

To Mertz MFM Center. This information will be used to further assist in my medical care. It should be mailed, faxed, or emailed to:
Heather L. Mertz, MD
Mertz MFM Center
3815 Forrestgate Drive
Winston Salem, NC 27103
Phone: (336) 930-9600
Fax: (336) 930-9930


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