AUTHORIZATION TO RELEASE INFORMATION

I request and authorize the above named doctor or health care provider to release my information to the organization, agency or individual named on this request.

PURPOSE(S) OR NEED FOR WHICH INFORMATION IS TO BE USED:

19621 Solar Circle, Ste 202

  • Parker, CO
  • 80134
  • (720) 851-1676
  • hollyslettendmd@comcast.net