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NOTE: DO NOT USE THIS FORM IN CASE OF AN EMERGENCY!

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hereby acknowledge that this form is unencrypted and not a secure means of electronic communication with my healthcare provider or facility. I agree to allow my healthcare provider or facility staff to reply to the email address indicated on this form, and to forward or share the information contained in this form, including any Personal Health Information (PHI), with other health professionals or associated staff using non-secure electronic communication methods such as email.

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