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I hereby release The Weinberg Residence and all others related to my care, of any liability or
responsibility in regard to the action described above.
________________________________________ ___________________
Signature of Resident Date
________________________________________ ___________________
Signature and Relationship of Responsible Other Date
________________________________________ ___________________
Signature and Position Title of Witness Date
Physician aware Y □ N □
Note: _________________________________________________________________
October 4, 2018