• East Bay Psychopharmacology Group

    3860 Blackhawk Road, Suite 120, Danville CA 94560

    P: (925)264-4069 F:(925) 277-1116 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. 

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