Forsyth Medical Center
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Disclaimer

I give Novant Health permission to use my health information as described in my "family health challenge" story, video or photo submission. Novant Health may share my offering on any of its websites, social media sites, internal and external publications, and other marketing mediums. Once this information is disclosed, it may not be protected by HIPAA. Granting this permission does not affect my ability to receive treatment, nor does it involve any type of payment or benefits.

My permission to disclose this information will expire five years after the date that I submit the form below. However, I may revoke this authorization at any time by sending a written request to the Novant Health Privacy Official at PO Box 33549, Charlotte, NC 28233-3549.