Patient Consent Form
I
date of birth
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January
February
March
April
May
June
July
August
September
October
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cell phone number
, pharmacy name
,hereby consent to the sharing
of my pharmacy data with Health Window or Health
Window's successor in title for the past 24 months and
until I withdraw this consent. I have been informed of the Health Care Co-ordination services
,and have read, understand and agreed to the
terms and conditions
of it.
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