Dr Sarah Allen Release of Information Consent Form

Release of Information Consent Form
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Your Name

First NameLast Name
Your Phone Number

Area CodePhone Number
Your Email
example@example.com
Name Of Person You Give Your Consent For Sarah Allen To Communicate With

First NameLast Name
Phone Number Of Person You Give Your Consent For Sarah Allen To Communicate With

Area CodePhone Number
Email Address Of Person You Give Your Consent For Sarah Allen To Communicate With. Leave Blank If You Don't Know It.
example@example.com
I do not consent to release the following information:
I give Dr. Sarah Allen permission to release and receive information regarding my treatment. I understand that I can withdraw my consent at any time.
Signature

Client signature (Client’s Parent/Guardian if under 18 years old) - Please use your finger if you have a touch screen or the hold down the left-click of your mouse to write your signature in the box below.
Please verify that you are human
Should be Empty: