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Release of Test Information
I give consent for the following individual to be able to access my health information and speak with Aveon Health doctors and staff members about my care, condition and treatments:
Name:
Relationship to Patient:
Phone Number:
I give consent for Aveon Health to leave a detailed messages to be left on my voice mail:
No
Yes
I give consent for Aveon Health to contact myself at my place of employment:
No
Yes
If yes, Employment Phone Number:
Signature
By typing my full name below, I am electronically signing this document.
Signature:
Patient / Responsible Party
Please Enter the Text You See Above:
By submitting this form you agree to our privacy policy and terms of service.
*Required field