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3500 Nostrand Ave, Brooklyn, NY 11229

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REQUEST FOR RECORDS

ADDRESS

I hereby authorize the release of my or copies of such and request that they be transferred to Dr. at 3500 Nostrand Avenue, Brooklyn, New York 11229. Fax #718-646-1911 : Phone# 718-769-2521.

To whom it may concern :
I do hereby give Finally Health Medical Services/ Healthquest permission to take a copy of my valid driver's license or a picture identification for their office files and this information shall not be used in any way without my knowledge or consent.

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