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

Consent to release information

Please provide the names and details of all practitioners or services whom you consent to sharing information with CFIH.
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.