ocvt.info - Special Permissions Parent Education

Patient Information Release – Special Permissions
This release is for the purposes of connecting patients and/or parents and families to share their individual stories or testimonies with other patients and/or parents and families that might benefit from learning more from an individual who has experienced something similar.

Your signature below indicates that we mail release your phone number and/or email address to the patient we have determined would benefit for the purposes of patient/parent/family education only. This release is voluntary and can be revoked at any time, except actions already taken based upon it. To revoke this release, please submit a written and signed revocation to any of our office locations via email, fax, or mail. The revocation will take effect as soon as we receive it.
PATIENT NAME:
DATE OF BIRTH:

MonthDayYear
Date
PARENT/GUARDIAN NAME (if applicable):
Phone NumberEmail Address
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
By signing below, you confirm that we will provide your information to the patient via the permissions you’ve indicated above.
SIGNATURE of Patient/parent/guardian:
Date:

MonthDayYear
Date
Should be Empty:

Patient Information Release – Special Permissions