Malin Dollinger, M.D., F.A.C.P. Medical Oncology
Clinical Professor of Medicine,  University of Southern California

Office: 310-378-4059
Fax: 310-791-0969

Medical Release Form

Date_____________ To: (facility)____________________________________

Please release to Malin Dollinger, M.D. the following medical records or other materials:

__________________________________________________________________________
Patient or authorized representative

_____________________
Date

Please deliver these materials to me or my representative,______________________
so I may send them to Dr. Dollinger

 

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