Adult Consent for 18 Years and Older

Adult Consent for 18 Years and Older
Name

First NameLast Name
Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Now that you are over the age of 18, we need your permission to share medical information with anyone other than you. Please sign the waiver below to let us know if we have your permission to share your information, and with whom.

I give my permission to share my medical information with:
Mom (Name)

First NameLast Name
Dad (Name)

First NameLast Name
Other (Name)

First NameLast Name
You may share:

All Lab resultsOnly Lab results, but not those related to sexually transmitted infections (STI) or pregnancyDO NOT SHARE any information with anyone but meI give my permission for my Mom or Dad to pick up any and all forms or prescriptions on my behalfI DO NOT give my permission for my Mom or Dad to pick up any forms or prescriptions on my behalf
Signature

Clear
Should be Empty: