Please complete this form to allow Spinal Diagnostics to share your personal health information with trusted individuals.
4. Acknowledgment
By signing this form, I authorize Spinal Diagnostics to disclose my personal health information to the individuals listed above.
I understand that my information may be re-disclosed and may no longer be protected by law.
I also understand that I may revoke this authorization at any time, in writing, except to the extent that action has already been taken based on this permission.
Signature: