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LIMITED RELEASE FORM INTROSPECT
Please identify below the name and relationship of any individual(s) whom you authorize to contact INTROSPECT on your behalf for purposes of verifying appointments, making appointments, or making billing inquiries. Without such an authorization we will not disclose this information, or any other information, including acknowledgement that you are a patient of INTROSPECT. NAME RELATIONSHIP 1. _____________________________________________________________________ 2. _____________________________________________________________________ 3. _____________________________________________________________________ 4. _____________________________________________________________________ 5. _____________________________________________________________________
DOB_____________ Patient Signature ______________________ RETURN TO INTROSPECT'S HOME PAGE
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