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

Today's date *

First name *

Last name *

Date of birth: *

Age

Contact number *

Email address *

Parent/Guardian full name

Relationship to client

Parent/Guardian contact number

Does the parent/guardian have legal custody

Yes (required)No

Consent to release information

I consent to Centre for Integrative Health (CFIH) *

receiving information providing information 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.

Client/guardian signature *

Clear

I have been informed and understand what information will be collected, who it will be collected from, and how it will be used.

CAPTCHA *