To: Dr. Norman Goldberg
11 Buttermill Avenue
Concord, ON
L4K 3X1
Canada
Fax: 1-844-615-5262
I understand the purpose of disclosing this personal health information to the person noted above and I also understand that I can refuse to sign this consent form.
*Please note: A substitute decision-maker is a person authorized under PHIPA to consent, on behalf of an individual, to disclose personal health information about the individual.