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Patient Consent and Release Form

Patient Authorization for Release of Information and Appointment of Authorized Representative

I am(Required)
Patient Consent(Required)
I understand that My Information may include, but is not limited to:(Required)
I authorize GYNESONICS and its Partners to use and further disclose My Information for the following purposes:(Required)
Without limiting the purposes for the use and disclosure of My Information set forth above, I understand:(Required)
APPOINTMENT OF AUTHORIZED REPRESENTATIVE:(Required)
Patient Name(Required)
Physician Name(Required)
Physician Address(Required)

FRM 06285.E

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