Right to Revoke: You have the right to revoke this consent at any time by giving us written notice. We will honor this request the day we receive your written notice. Please understand that it will not affect any action taken before we received your revocation and we may decline to treat you or to continue treating you if you revoke this consent.
Patient Responsibility: We request timely notification of any changes to your personal information we maintain for you, such as but not limited to, health history information, address, telephone number, active insurance information, and change in employer.
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Patient Signature Date Witness