By signing below, I understand and acknowledge that I may revoke this waiver at any time, in writing. In addition, I understand that in cases where medical records were released prior to my revocation, such revocations will not apply.

I understand that this disclosure is not mandatory and that signing this waiver is my choice. I understand this waiver may not be conditioned upon a treatment.

I understand that upon submission of this waiver, I will receive a copy and that copy shall be deemed an original.