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Salem Orthopedic Surgery 
A Service of SALEM REGIONAL MEDICAL CENTER

Dominic Peters, M.D.
Lee Simon M.D.

Patient Forms

If you are a new patient, please print and complete the following forms and bring them with you to your first visit:

Adult Consent Form
Pediatric Consent Form

If you wish to have a copy of your medical records released to another party, please complete the authorization form below and bring it to our office:

Authorization for Disclosure of Protected Health Information
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