PERSON BEING REFERRED
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PARTICIPANT CONSENT
By checking this box I understand that the Arizona Living Well Institute and/or one of it’s partners will be contacting me with information on the Healthy Living: Self-Management of Chronic Conditions workshops. My participation is voluntary. I understand that any information I provide will be kept confidential. I give the Arizona Living Well Institute and the referring agency or physician permission to discuss my use of this service. Written or verbal consent is kept at the referring agency’s location.

REFERRING PROVIDER
Are you a referring provider?