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5) When Dr. Gary J. Schmidt LLC is attempting to contact you regarding

upcoming appointments or scheduling tests, would you like us to leave a

message on your home or cell phone if we are unable to reach you?

(circle one)

YES

NO

6) When Dr. Gary J. Schmidt LLC received your laboratory or other test results, would you like us to leave a message on your home or cell phone if

we are unable to reach you?

(circle one)

YES

NO

7) Dr. Gary J. Schmidt LLC and its workforce members are hereby Released from any legal responsibility or liability for disclosure of any of my Protected Health Information as indicated and authorized herein.

___________________________________________ Print Patient’s Name (or personal representative)

__________________ Date

___________________________________________ Patient’s signature (or personal representative)

__________________ Witness

___________________________________________ Relationship to Patient

__________________ Date

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