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Page 1: sa1s3.patientpop.com · & SPORTS MEDICINE RECORDS RELEASE I authorize the release of my medical records to: Performance Orthopaedics & Sports Medicine David B. Dickerson, MD 780 Rt
Page 2: sa1s3.patientpop.com · & SPORTS MEDICINE RECORDS RELEASE I authorize the release of my medical records to: Performance Orthopaedics & Sports Medicine David B. Dickerson, MD 780 Rt
Page 3: sa1s3.patientpop.com · & SPORTS MEDICINE RECORDS RELEASE I authorize the release of my medical records to: Performance Orthopaedics & Sports Medicine David B. Dickerson, MD 780 Rt
Page 4: sa1s3.patientpop.com · & SPORTS MEDICINE RECORDS RELEASE I authorize the release of my medical records to: Performance Orthopaedics & Sports Medicine David B. Dickerson, MD 780 Rt
Page 5: sa1s3.patientpop.com · & SPORTS MEDICINE RECORDS RELEASE I authorize the release of my medical records to: Performance Orthopaedics & Sports Medicine David B. Dickerson, MD 780 Rt
Page 6: sa1s3.patientpop.com · & SPORTS MEDICINE RECORDS RELEASE I authorize the release of my medical records to: Performance Orthopaedics & Sports Medicine David B. Dickerson, MD 780 Rt
Page 7: sa1s3.patientpop.com · & SPORTS MEDICINE RECORDS RELEASE I authorize the release of my medical records to: Performance Orthopaedics & Sports Medicine David B. Dickerson, MD 780 Rt

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