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I understand that any release which was made prior to my revocation in compliance with this authorization shall not constitute a breach of my rights to confidentiality. I have given my consent freely voluntarily and without coercion. I may revoke this authorization at any time providing I notify Gilbert Pediatrics Inc. in writing to that effect. I understand that a photocopy of this authorization is considered acceptable in lieu of the original. There will be a charge for additional copies...
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