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Healthcare Seeker
Send this information to: *
Consent
Enter your information.
*so that we can let you know when the referral has been completed
I have spoken to the patient/client above and they have agreed for me to fill out this form on their behalf. Patient/client and I both understand that this is only for purposes of communication with ICAN!, myself and the selected health center. Text/Emails are sent to make sure the patient/client can get their contraception of choice without barriers.
Referral Consent

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