Consent to Share Information

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.
Patient's Full Legal Name*

First NameLast Name
Patient's Date of Birth*

YearMonthDay
Contact Phone Number

Area CodePhone Number
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:
Indicate any specific items to share if applicable
INDICATE ANY SPECIFIC ITEMS TO SHARE IF APPLICABLE
Name of Client or Parent/Guardian (if client is under 18 years of age):*
Signature*

Clear
Date

MonthDayYear
Date
To Share Information with/from:

Please complete all fields
Name*
e.g. Parent Name, Spouse Name, New Physician Name, Clinician Name
Relationship*
e.g. Mother, Father, Spouse, New Physician Name, Clinician Name
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone Number*

Area CodePhone Number
Fax Number*

Area CodePhone Number
Email Address
Should be Empty: