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Img 20220421 0001
Img 20220421 0001
Img 20220421 0001
MAHATMAGAND@
Ofiice of the Medical Manager
Address : Private Bag X 13, Mount Edgecombe' 4i100
ooNSENTToPRoVIDEINFoRMATIoNToATHIRDPARTY
tx ft mn-rl-
I, r.l xt F.ll S.-i*l trcL Sq3 ( G;; Jpatient / legal-guardran/ er<eeuter) hereby
f\ (relationshiP to Patient
consent to the release of mY I mY
) L\ r )
WITNESSES:
( ou eJ o c-L
1, NAME: M SIGNATURE;
2. NAME: SIGNATURE: