• Consent to Share Information

  • Please Note:  

    Our online forms use SSL encryption to maintain secure transmission of medical information.

    Forms must be submitted online.

  • In order to share information between the Possibilities Clinic and other healthcare and support services institutions, we require authorization from the patient or parent/guardian for children under the age of 18 years.

  •  - -Pick a Date
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  • I consent to release information for the above-named patient, between the Possibilities Clinic and the individual/institution indicated below, for the purposes of sharing information and/or:

  • Clear
  •  - -
    Pick a Date
  • To Share Information with/from:

    Please complete all fields
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  • Should be Empty: