I hereby give permission to disclose, discuss and speak with the individuals listed below regarding my personal health information or
I understand that unless specifically listed below, Southeastern Dermatology Group, P.A. cannot speak to any individual
concerning my medical or financial information including, but not limited to appointments, test results, prescriptions, school or work
excuses. This includes my spouse, children, siblings, or parent, if I am 18 years or older. I understand that I can amend this list at any time by
submitting a request in writing.