WebBy signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. By signing this form, I understand that: Webrite aid consent form Clinic Yes No Screening Questionnaire and Consent Form Patient Information: (Patient to complete)* *Patient Name: *Date of Birth: *Age: *Phone# …

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2016 Rite Aid Screening Questionnaire and Consent Form Fill …

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