Consent Release And Indemnity Agreement Page 5

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I further state that I am of lawful age and legally competent to sign this aforementioned release. The
procedures, alternatives and risks have been explained to me and I have been given the opportunity
to ask questions. I understand it is my responsibility to inform the staff if there are any changes to my
medical history. I understand the terms herein is contractual and not a mere recital. I have signed this
document of my own free act.
I HAVE CAREFULLY READ, UNDERSTOOD AND ACKNOWLEDGE ALL OF THE ABOVE STATEMENTS.
Client
Date
Management
Date
IZ Call for Appt: 512 – 814 - 5522

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