To whom it may concern:

This notice is to inform you that I would like to have my personal data deleted from your records. My full name and contact information are listed below:

Email *

Phone *

Last Name

First Name

Address

Street Address

City

State

Country

Postal code

The reason I am requesting deletion of my personal data is as follows:

Consent is being revoked for personal data processing

The information that I am specifically aware of, that you process or retain, is as follows:

Full Name
Address
Phone Number
Email Address
Treatment History
Before & After Photos of Patients (if applicable)

Please respond via email to confirm that my request has been honored.

Sincerely,

Signature 1v44

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