Consent for Verbal Release of Medical Information

Account #:

Today's Date:

I authorize the release of my medical information, i.e. blood test results, x -ray reports, pathology reports, etc., to my immediate family, care giver, pharmacist and any physician who participates in my care.

Your Name:

I authorize general messages (i.e. x- ray and lab results, appointment reminders, etc.) to be left on my answering machine or voicemail.

I do not authorize any information to be given to anyone other than myself.

Please tell us with whom we may discuss your medical information and treatment if you are not available

Name/Relationship

Name/Relationship

Name/Relationship

Patient or Guardian’s Signature:

Date: