Medical release form
Please print and fill out this form as needed, send it by August 18, 2023 to:
FamiliaHealth Chiropractic
to: familiahealthchiropractic@gmail.com
Name: __________________________
DOB:____________________________
Phone number: ___________________
Consent
By checking the following, I agree to release my confidential information collected by Dr. Olga Schwend at FamiliaHealth Chiropractic for my benefit with the following professionals.
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Agreement
O I hereby give my consent for Dr. Olga Schwend to release only necessary personal information to the individuals and organizations named below for my benefit.
O I am aware of and comfortable with Dr. Olga Schwend releasing my identifying information as well as details pertaining to my chiropractic care where required.
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My Chosen Professionals
Name: ________________________
Profession: ____________________
Contact Information: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Other: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Consent to Release Information
O I consent to the exchange of information between Dr. Olga Schwend and the aforementioned professional.
_______________________________
Signature
_______________________________
Print name