Pediatric Healthcare Connection - Client Choice

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I, (Patient/Parent/Guardian) understand it is my right to select a healthcare provider of my choice. PHC has informed me if for at any time, for any reason I can choose to change my services to another healthcare provider, it is my right to do so.

I have chosen Pediatric Healthcare Connection to provide the below services:


I request the above services for be transferred from:
to Pediatric Healthcare Connection as of
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for the reasons of

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