Consent to Release and Exchange Info

East Bay Psychopharmacology Group

3860 Blackhawk Road, Suite 120, Danville CA 94560

P: (925)264-4069 F:(925) 577-7608 E: ebpgoffice@comcast.net

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.
Patient Name *

First Name Last Name Suffix
Patient Date of Birth *

Month Day Year
Date
Parent/Guardian Name Completing Form: *

First Name Last Name
Professional Name (Physician/Therapist/Etc.) *

First Name Last Name
Company/Office Name
Professional/Office Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Fax Number

Area Code Phone Number
Parent/Guardian Signature for Consent to Release Information *

Clear
Date of Signature *

Month Day Year
Date
Should be Empty: