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I authorize IMP to use Impact SIIS for reporting vaccines I receive to the State of Ohio Department of Health. (This is for our office inform the Ohio Department of Health when you receive a vaccine.)
I authorize IMP to exchange my healthcare information with my other healthcare providers through an encrypted electronic data exchange. (This is for us to be able to send your medical information when we refer you to another doctor.)
I authorize IMP to take photographs and use those images taken for diagnostic and treatment purposes. (For example, your provider may take a picture of a mole or rash in order to determine at a later date if the condition has improved or progressed.)

My signature implies consent to the above statements.

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