This preview shows page 1. Sign up to view the full content.
Unformatted text preview: I hereby release the Medical Office of MJ Scheinbaum, MD, its representatives, agents, consultants, and its counsel from all liability and all claims of any nature whatsoever pertaining to disclosure of information, or of any professional opinions, findings, or recommendations as contained in the information, records, and reports to which this release applies. Date: ______________________ Full Name: _____________________________ Signature: _____________________________ Social Security Number: __________________ Date of Birth: ___________________________ Adress: _______________________________...
View Full Document
This note was uploaded on 10/27/2011 for the course PHYCOLOGY 101 taught by Professor Eins'tein during the Spring '11 term at Albany Medical College.
- Spring '11