Release of Information Consent Form

Complete the information below
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Read the consent statement. Press “Previous” to go back and make corrections
You will confirm the entered data on the next page. Signatures will be taken at the office visit
Click Submit. Your consent form is ready to be printed.
Print the completed consent form and bring it to your next appointment

Your Name, Patient or Parent/Guardian *

Name of Patient, if Minor

Minor's Date of Birth, if Applicable *

Name of Authorized Office *

Is the Authorized Office Sending Information TO us or Receiving Information FROM us? *

Sending

Receiving

Is information is being sent TO or FROM the following Offices? *

From

Office 1 Name *

Office 1 Phone

Office 1 Address

City

State/Province

Zip/Postal

Office 2 Name

Office 2 phone

Office 2 address

City

State/Province

Zip/Postal