CHART PERMISSION

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I give permission to
to have access to my chart, email the MD regarding my case, and is able to make appointments for me as well. I understand that if I miss any appointments made my the above and do not cancel within the 48 business hours, I am responsible for the No Show Fee.
Patient Name(Required)
MM slash DD slash YYYY
Chart Permission will be submitted to Sayana Medical Spa and Wellness Center