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Data Removal Request

HelloNote Data Removal Request
I, , hereby authorize HelloNote (E Medical Records Live Inc.) to
archive the following information. I acknowledge that this cannot be undone and I have the authority to
make this decision.

Data to be removed:
Patient ID:

Case name:

Case date:

Note number and type:

Note date:

Reason for removal:

Remove (Select):

Case Above

Note Above

Requestors information:
Date of request: August 30, 2025

Clinic name:

Your name (first, middle initial, last):

Thank you.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

August 19, 2025 5:40 pm CDT

Data Removal Request Uploaded by Steve Glukh - [email protected] IP 47.162.17.96