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Withdrawal of Consent

I the undersigned do hereby withdraw my consent from the below listed practice to use my information in regards to the processes indicated below. I request that the below listed practice remove my information from their systems in accordance with the The Protection of Personal Information Act (POPIA).

I understand that, should my medical aid or any medical professional need access to this information from the below practice that it will no longer be available as I have requested that it be deleted and destroyed and I accept any and all liability with regard to this request.

Name of the healthcare practitioner treating yourself or your legal guard.


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