9 Holly Hill Drive
Petersburg, Virginia 23805-2559

(804) 733-9490

FAX (804) 733-3564

10320 Memory Lane, Suite A
Chesterfield, Virginia 23832

(804) 748-9553

FAX (804) 748-0460

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The office of Virginia Perio is expressly authorized to answer questions posed by the Personal Representatives listed below and openly discuss with them my condition, treatment, test results, prognosis, insurance claims/payments, any other financial matters, and all other information pertinent to my care, even if I am fully competent to ask questions and discuss my condition. This document constitutes a full authorization to disclose any Individually Identifiable Information to the Personal Representatives named in the Authorization.

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