3.
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I have completed the “Patient Registration Form” and (if applicable) “Patient Consent for
Treatment of a Minor and/or Release of Information to Others” to the best of my ability and I request that information on those forms be included in my/my child’s health records.
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4.
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I give my consent to be examined and/or treated by Shalom Health Care Center’s health care providers. I understand and agree that any in-depth examination and/or procedure will be explained to me before I give my consent.
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5.
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All documents, policies, and procedures included in the Shalom Health Care Center intake
process have been explained to me, and I understand that if I have any questions, I may ask a Shalom staff member at any time.
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