Florida Facial Surgery Center, James Gift D.D.S. – AUTHORIZATION FOR THE USE OR DISCLOSURE OF HEALTH INFORMATION

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Florida Facial Surgery Center, James Gift D.D.S. - AUTHORIZATION FOR THE USE OR DISCLOSURE OF HEALTH INFORMATION(Required)
Can we leave messages for you on answering machine or with a household family member?
Can we leave voice messages or texts on your cell phone?
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If you choose please list by name and relationship the persons with whom we may share your healthcare or payment information.
First and Last Name
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