Consent to Release Information 📝
Please fill out the form to authorize the release of your medical records and details.
Patient Name
*
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Health Card Number
*
Doctor or Specialist Name
Doctor's Fax
Doctor's Email
example@example.com
Records Requested
Lab Results
Medical Visit Notes
Diagnostic Reports
Details
Records will be sent to HavenPoint Health by secure email at veterans@havenpoint.health or fax at 902 442-6896.
Date
*
-
Month
-
Day
Year
Date
Patient Signature
*
Submit
Submit
Should be Empty: