Adult Consent Form

419 W. Wackerly

Midland MI 48640

Main Phone: 989.631.9515

Fax# 835.6824

Hugo Juarbe, M.D.     989.839.8804
Jennifer Grossman, D.O.     989.374.0142
Brittany Reiber, P.A.-C     989.631.9515
Jenna Lyons, C.P.N.P     989.631.9515
Cheri Daniels, C.P.N.P     989.631.9515
Ashley Badour, Care Mgr     989.631.9515

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*