18+ Year Consent

18+ Year Consent
Today's Date*

MonthDayYear
Date
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Patient Email*
example@example.com
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I hereby authorize Waggoner Pediatrics of Central Iowa, either orally or in writing, to release information to:
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient*
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient
Any and/or all personal health information with the exception of the following:
Specific authorization for the release of information protected by State or Federal law
I specifcally authorize the release of data and information relating to (check all that apply):

Substance abuse (alcohol/drug)Mental Health (including psychological testing, ADHD related information)HIV related information (AIDS related testing)
Signature of Patient*
Today's Date*

MonthDayYear
Date
(1) I understand that this authorization will expire three years from my last date of service.

(2) I understand that I may revoke this authorization at anytime by notifiying Waggoner Pediatrics of Central Iowa in writing.

By signing below, I acknowledge that I have read and understand this authorization.
Signature of Patient*
Today's Date*

MonthDayYear
Date
Should be Empty: