CONSENT FOR RELEASE OF MEDICAL INFORMATION - Patient Intake

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PATIENT INFORMATION

Patient Name:

Chart Number:

Address:

Phone

Date of Birth:

By signing below, I understand I am giving my permission to have any or all of my medical information, including financial information, released to the following persons:

Name:

Phone:

Relationship:

Emergency Contact?

Yes

No

Name:

Phone:

Relationship:

Emergency Contact?

Yes

No

Signature:

Use your mouse or finger to sign in the box below.

Date of Birth: