Consent to release information form
If you consent to Centre for Integrative Health receiving information from or providing information to another professional or service, please complete this form in its entirety.
Client Identifying Information
Date of birth:
Parent/Guardian full name
Relationship to client
Parent/Guardian contact number
Does the parent/guardian have legal custody
Consent to release information
I consent to Centre for Integrative Health (CFIH)
both, receiving & providing information
to/from the following practitioners/services
Please provide the names and details of all practitioners or services whom you consent to sharing information with CFIH.
with the following restrictions/provisions:
Please provide any restrictions/provisions around the sharing of your confidential information.
I have been informed and understand what information will be collected, who it will be collected from, and how it will be used.
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