Release of Information

Release of Professional Information

First Name

Last Name

Date

Release sent to

I hereby authorize Dr. Alison Block to...

Obtain information pertaining to the aforementioned patient

Release information pertaining to the aforementioned patient

This authorization can be revoked at any time by the person signing below and will expire when treatment ends.

Date

Patient Signature (or Legal Guardian)

Sign Here

Relationship, if other than patient signing: