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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