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.
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: