I, , hereby PERMIT the providers of South Coast Neurology, Inc. to disclose my health care prognosis only to the family members listed below. I understand that this authorization is voluntary.
Check this box if you DO NOT PERMIT South Coast Neurology, Inc. to discuss your health care prognosis to any family member
1919 State St, Suite 203 Santa Barbara, CA 93101 Tel: (805) 220-4300