Consent to release personal medical information

Consent To Release Personal Medical Information

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CONSENT TO RELEASE PERSONAL MEDICAL INFORMATION

(Patient’s full name)

hereby consent that my lab/ radiology/ medical report(s) shall be collected on my behalf by

Collector’s name

and/ or sent via email to:

Email Address

ALTERNATE CONSENT: CONSENT BY GUARDIAN FOR MINORS/ THE INCAPACITATED.

(Parent/ Guardian name))

hereby consent that the lab/ radiology/ medical report(s) for

Patient name

who is my

specify relationship

shall be collected by

Collector’s name

and/ or sent via email to:

Email Address

I further consent that incase of any breach of protected personal information through the mentioned channel(s), I bear full responsibility.

NB: Reports will be dispatched to referring doctors/ clinicians/ institutions where applicable. Persons collecting on your behalf will be required to produce identity proof (e.g. national ID, passport).

Patient/ guardian signature:

Visit No:*

Visit No:

Phone

Date Time Title*

Select Date ×

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