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Record Release Form

Existing Patients:

Please print the release form and either fax the completed form to 833-464-3281 or mail/dropoff to 1691 Innovation Drive Ste 2100, Blacksburg, VA 24060

Note: When filling out the form, please list "APCA" as who you "authorize and request."

New Patients:

Please complete the form with your child's pediatrician's name and have your pediatrician's office fax it to us at 540-408-0428

Because Every Child Deserves Top-Notch Care

Don't Wait - Get Your Child the Care They Need Today

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