Financially Responsible Person/Guarantor
If the patient is a minor or is not financially responsible for themselves, please fill out contact information for the person / guarantor who is financially responsible for the patient.
Release of my medical records to my personal electronic portal authorization. I understand that this health information may include HIV-related information and/or information relating to diagnosis or treatment of psychiatric disabilities and/or substance abuse and that by signing this form, I am authorizing such information to be disclosed. This authorization is effective indefinitely unless revoked in writing.
There are many sections below, please fill out the sections for which you have symptoms:
IF YOU HAVE BREATHING SYMPTOMS
IF YOU HAVE NASAL / EYE / EAR ALLERGY SYMPTOMS
IF YOU HAVE SINUS SYMPTOMS
IF YOU HAVE HIVES
OTHER ALLERGIC HISTORY