Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Primary Phone Number
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Please enter a valid phone number.
DUE TO THE PRIVACY CONFIDENTIALLY ACT,
please list the people that you approve to have access to your information as stated below:
Appointment Scheduling
*
Please include your relationship to those listed.
Billing Information
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Please include your relationship to those listed.
Medical Records Information
*
Please include your relationship to those listed.
AUTHORIZATION TO LEAVE MESSAGES:
I authorize Lakeside Clinic physicians and staff to leave messages regarding my medical condition, such as lab reports, other test results, and medications on my voicemail. This authorization will be in effect until I have given written notice to Lakeside Clinic.
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Yes, I authorize Lakeside Clinic to leave voicemails regarding my medical condition.
No, I do not authorize Lakeside Clinic to leave voicemails regarding my medical condition.
AUTHORIZATION TO CONTACT AT EMPLOYMENT:
I authorize Lakeside Clinic physicians and staff to leave messages at my work place if they are unable to leave a message with my primary phone number for any reason. I may revoke this authorization by giving written notice to Lakeside Clinic.
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Yes, I authorize Lakeside Clinic to leave messages at my work place.
No, I do not authorize Lakeside Clinic to leave messages at my work place.
By signing this document, I agree to the privacy and confidentiality conditions chosen above.
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Today's Date
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Month
-
Day
Year
Date
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