Any contact information listed on this form, including phone numbers and email, will be used by this office to contact you about future appointments, billing, and routine correspondence.
Consent for Others to Access Your Account & Records
(i.e. spouse, partner, adult child, etc.) to discuss and/or obtain my NOPArelated medical and account information in person, by phone, or by mail. I understand I may revoke given consent either in writing or in person at any time.
If yes, please list
Please indicate which problems you now have or have had in the past.
Please indicate if you have had any of the following:
I hereby consent and give my permission to the doctor (and the doctor’s assistants or designated replacement) to administer and perform such procedures upon me or my minor child as the doctor deems necessary.
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