PERMISSION TO DISCLOSE PERSONAL MEDICAL INFORMATION

Patient Name:

DOB:

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Preferred telephone number:

Additional telephone numbers:

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Do you authorize The Pediatric Center leave a voice message with medical information at these numbers?

Yes No

Please be aware that you may revoke this authorization at any time, but it must be in writing.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Name of Patient or Legal Guardian:

Date:

Your information will be encrypted.