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MEDOL CONSENT/AUTiORIAIO{/RELEASE
My srgn.tre berow.cknowldos rhdr all sotemenrs prcvided by de in rhis appliarion arc rrue a.d
coftct ro rhe besr of hy knowledEe and belier. .nd I funh
anytarr or ny nedr@r Ecord6 rbm .ny soorc, incrudrng n.iions, insuan@ ottices, docto6, hospirars,
and/6r orher insrirdroG or pubnc .urhontis. This genEr mdicll cldse will also aurhori* the Elease

I UNOERSTANO THAT FALSIFICATION


TERMINATIoN OF EMPLOYMENT. My .lonatuE rurth.r .cxnowl.dges my con*nl lo ny/all physicll
eEmrn.rron6 and di.gnostic t5ring:

rheEby cediryrh.r rhe peEon.l ro rhe besr or my knowr.dge-

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MEDICALLY NT

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