• Statement of Release

    Authorization to Request and/or Release Information
  •  /  /
    Pick a Date
  •  -
  •  -
  • I understand that I have no obligation whatsoever to disclose the requested information and that I may revoke this consent at any time by informing the Center for Anxiety and Mood Disorders or the above named parties. In consideration of this consent, I hereby release the Center for Anxiety and Mood Disorders and the above named parties from any and all liability arising therefrom.
  • Clear
  •  /  /
    Pick a Date
  •  
  • Should be Empty: