RELEASE OF INFORMATON, CONSENT FORM

PATIENT RELEASE OF INFORMATION FORM
I First Name* Last Name* hereby authorize Bermuda Pain Relief Center to disclose my health information, including but not limitted to, office notes, laboratory & radiology results.

Your medical records will only be shared with your General Practitioner, your referring Physician and any other health care provider of your preference.

Please advise us if you would prefer us to limit the sharing of your medical
Documents released include:

Office notesRadiology or laboratory resultsOther
Patients Signature*

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Date*

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Email*
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PATIENT RELEASE OF INFORMATION FORM