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Consent to share confidential information with a third party

Consent to Share Confidential Information with a Third Party

Patient Details

I give consent to the sharing of my medical information with:

What type of information can be shared:

All information:
Test Results:
Appointment Information:
Medications:
Other Information:

Please tell us if this consent is permanent or for a short period of time:

Is this consent permanent?

If consent is not permanent, please provide a start date and end date for the consent:

Please note: It is your responsibility to inform us if you change your mind and wish to remove your consent to share your medical information with the above mentioned person.