I understand that any personal health information may be subject to redisclosure once downloaded from this website, and may no longer be protected by applicable Federal and State privacy laws. I hereby release, discharge, and agree to hold NorthKey Community Care harmless from any liability that may arise from the information entered on this website.

Information entered here will NOT be stored for any purpose.

If you wish to print out a form and sign it, you can either drop it off at one of the NorthKey locations or email it to us at: Nk_him@northkey.org.

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