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And when I am not physically present including disclosures by telephone facsimile or e-mail or regular mail. Other Conditions of Disclosure I understand that this consent may be revoked by me at any time by written notice to the practice. Therefore I hereby give my permission for Vein Specialists of the Carolinas and Doctor David Draughn and his staff to disclose my personal medical information to the following individual Name Relationship to Patient Conditions for Disclosure Check the item s...
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