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Release of Information

Date of Upcoming Service
Do we have person to leave a voicemail regarding your appointment at the phone number provided?
Yes
No
Do we have permission to text this phone number appointment reminders?
Yes
No

 

Release of Information

Below, I have listed the names of anyone that I have authorized to have access to my personal health information.

If there are no one to release information to, please select the Not Applicable selection button.
Not Applicable

By signing below you agree you have reviewed the documents and understands the information provided for each.

Date and time
:
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