Information Sharing Consent Form

Information Sharing Consent Form
CONSENT

I understand that this consent is purely voluntary. If I have any concerns, I've discussed them with Bill. I know can discuss any concerns with him and by doing so, all questions were answered accordingly and to my satisfaction.

I understand that I can withdraw my consent at anytime. By signing below, I expressly give my consent to allow William (Bill) Zormeir to discuss my case and treatment with his immediate family.
Age of Consent*

I hereby declare that I am of legal age and I freely give my consent to the information sharing.I hereby declare that I am below legal age and I am accompanied by my parent/guardian who gives his/her consent on my behalf for the information sharing.
Name*

First NameMiddle NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Parent/Guardian

First NameMiddle NameLast Name
Signature of Parent/Guardian

Clear
Date

MonthDayYear
Date
Should be Empty: