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Waiver of Confidentiality
As a patient of {Doctor/Clinic/Hospital}, with the acknowledgment that the information will be used for medical diagnostic and treatment purposes:
I, the undersigned, hereby waive my right of confidentiality regarding the following medical information: {information}. I waive my right of confidentiality for {Clinic/Hospital} only and any of its medical staff, personnel, representatives, and agents.
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Signature
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Date
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