Medical Information Sharing

Release of Medical Information

For clients of Zilber's Way willing to get treated by Sammakko
Full Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Phone Number*
Please enter a valid phone number.
I approve the exchange of my medical information between Zilber's Way and Sammakko. I understand that the information exchanged between the therapists will stay confidential between the two, and would not be shared to a third party without my written consent. I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time in writing.
Signature Date

DayMonthYear
Date
Signature*

Clear
Should be Empty:

Release of Medical Information