Adult Consent Form

Adult Consent Form
Adult Consent Form
419 W. Wackerly

Midland MI 48640

Main Phone: 989.631.9515

Fax# 989.835.6824
Hugo Juarbe, MD

Jennifer Maxam, DO

Cheri Daniels, PA-C

Britany Cline, FNP-BC

Brittany Reiber, PA-C

Jamie Kretz, RN, Care Manager
Patient Name*

First NameLast Name
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
This form is to allow us to release test results or other health information directly relevant to your ongoing care to whomever you authorize. This is not a release of medical records. This information will be used in the event that you are not available to receive your test results or other care information and would like that information given to a designated person; for example, your parent, aunt, grandparent. THIS IS NOT A MEDICAL RELEASE FORM.

This authorization is valid for one year, unless updated and initialed by the patient.

Test results may be released to the following:
Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Signature*
Date*

MonthDayYear
Should be Empty: