• Authorization to obtain and release confidential information for the purpose of assessment and future treatment.

    In this form, please provide the contact information for any of the following providers you find necessary: your current and/or past nutritionist, therapist, physician, specialist, psychiatrist, treatment venter, coach, school/university personnel and any family members with whom you choose to have Anne Till Nutrition Group communicate as part of your treatment team. If you do not want us to share information or have access to informations, please indicate this in the next question of this form.
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  • I {patientName} hereby authorize Anne Till Nutrition Group to obtain and release information regarding past and current treatment for myself {patientName} to and from the following people and/or organizations listed below. This information may include full health history, general and specific information regarding: nutritional, lifestyle, medical and/or psychological or social assessment/evaluation/counseling/treatment and progress notes, laboratory tests, growth charts, special evaluations/testing, diet prescriptions and provided dietary and lifestyle guidelines, school performance, social and emotional functioning, special learning problems or capabilities, educational testing, etc.

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