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Procedure Consent
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HIPAA
Compliance
1
Patient Information
*
This field is required.
First Name
Last Name
Date of Birth
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2
Procedure
This is authorization for the performance of the following procedure(s):
Ultrasound
Pellet Insertion
IUD Removal and/or Insertion
Sonohysterogram
Vulvar Biopsy
Endometrial Biopsy
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3
Provider
*
This field is required.
This procedure is to be performed under the direction of:
Julie Morin, WHNP-BC
Abbie Leddy, NP-C
Other
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4
Terms of Release
*
This field is required.
Please review all terms before selecting the box.
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5
Authorized Person
*
This field is required.
Please select the person signing this authorization.
Patient
Parent
Legal Guardian
Other
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6
Authorized Person Information
First Name
Last Name
Date of Birth
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7
Authorized Person Signature
*
This field is required.
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