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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:
I give consent for Aveon Health to contact myself at my place of employment:
If yes, Employment Phone Number:

Signature

By typing my full name below, I am electronically signing this document.

Signature:

Patient / Responsible Party

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By submitting this form you agree to our privacy policy and terms of service.

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