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I acknowledge the risks associated with unsecured email transmission, including the potential for unauthorized access to my personal and health-related information. I understand that the information will be distributed via email without encryption, which may pose security risks. By providing my email address, signature, and clicking 'SUBMIT', I consent to the unsecured transmission of my information. I am aware of more secure communication methods, such as calling our office directly, and understand that these alternatives are available and have been offered to me.

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