Authorization for client file release

Authorization

for Release of Patient Files
I, blanks* , authorize Sandra Strangman, owner of Body Balance Therapeutic Massage, Acupuncture, Cold Laser and MOT Treatments, to release my file to the therapist of my choice or to my new clinic of choice as below:
Name of your Body Balance Therapist that you wish to continue with OR the name of your new clinic of choice *
Name the therapist/clinic that you would like your files sent to
Address of your new clinic (if available but not required)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
If you need any information, we are happy to respond
Any questions?
Signature *

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