Consent to Disclose Personal Health Information

Patient Name:(Required)

Partner Name:

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Email Address:(Required)

Name of Patient:(Required)

Patient's Birth Date:(Required)

Name of Patient:

Patient's Birth Date:

The undersigned hereby authorizes and requests: (Name and address of Physician / Institute)

Physician / Institution:(Required)

Mailing Address of Physician:(Required)

Telephone:(Required)

Fax:

To disclose the following personal health information (Description of personal health information to be disclosed and dates of contact/hospitalization or simply "any information requested"):(Required)

Draw your signature into the box below. (Patient's Signature):(Required)

I understand this is a legal representation of my signature.

Draw your signature into the box below. (Partner's Signature):

I understand this is a legal representation of my signature.

Date:(Required)

Revised: April 15, 2008