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Records Release Form

NORTH COUNTRY EYE CARE ASSOCIATES

10 Benning Street, Suite 10
West Lebanon, NH
Phone: (603) 678-4759 / Fax: (603) 790-8047

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I hereby authorize release of any information, including the ocular and refractive diagnoses, findings and records of any treatment from pertinent visit(s). Thank you for your prompt attention to this request.

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