East Bay Psychopharmacology Group
3860 Blackhawk Road, Suite 120, Danville CA 94560
P: (925)264-4069 F:(925) 577-7608 E: email@example.com
Said A. Ibrahimi, MD J. Kirk Hartman, MD Ameek Mundi, DO
CONSENT TO RELEASE AND EXCHANGE INFORMATION FORM
I am requesting you to provide all pertinant medical information about the patient listed below to East Bay Psychopharmacology Group. This information may be in electronic form such as a PDF file sent via email or by hard copy mailed to the above address.
I am giving my consent to both parties to share and exchange information as appropriate for the care of the patient.