This consent may be revoked at any time, upon notice of the person who has signed below, except when action has already been taken. Without revocation, this consent will expire one year from date of signature.
The types of medical information above cannot be released without my specific consent and knowledge. I hereby release Kū Aloha Ola Mau and its staff from all liability and all claims of any nature pertaining to the disclosure of information of any professional opinions, findings, or recommendations contained in these records.