Loop Recorder Insertion or Removal

I authorize and direct Brett Gidney, M.D., with associates or assistants of his or her choice, to perform the procedure of Implantable Loop Recorder:

Name

First Name Last Name

Email

example@example.com

Phone Number

- Area Code Phone Number

I further authorize the physician(s) and assistants to do any other procedure that in their judgment may be necessary or advisable should unforeseen circumstances arise during the procedure.

Please sign using your finger or cursor. Clear

Date

Loop Recorder Insertion or Removal

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