Jeffrey A. Snyder, M.D., F.A.C.S.
I give permission for Genitourinary Surgical Consultants to relay my medical information to: (check all that apply)
________ Leave a message on my answering machine
________ My spouse. Name: ____________________
________ My children. Name: ___________________
OR
________ I elect to have all medical information relayed directly to myself and no one else.
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Signature:
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Date: ___________________________________________________________________________
What contact member would you like our office to call you at?
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Genitourinary Surgical Consultants
4500 East 9th Avenue
Suite 530
Denver, CO 80220
Tel: 303.320.0200
Fax: 303.320.4111
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