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Medical Release Form
909-594-3382
Medical Release Form
Fairway Children's Medical Group,2707 East Valley Boulevard, Suite 215, West Covina California
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Pay My Bill
Medical Release Form
909-594-3382
Medical Release Form
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Are you a new or returning patient?*
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Child’s Last Name*
Date of Birth*
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Reason
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Sports Pre-participation Exam
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Appointment Change needed
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Primary Caregiver Phone*
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Secondary Caregiver Name
Secondary Caregiver Phone
Email*
Phone*
Preferred Language
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and I am at least 13 and have the authority to make this appointment.
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