Patient Name
Patient's Date of Birth
This letter authorizes
to release a complete set of records, including my x-rays, chart notes and all other records or those of my minor child
to Chestermere Lifepath Wellness, Ltd. located at the above-noted address.
I represent that I have legal authority to authorize the release of records requested. I understand that the information in my/my minor child’s health record may include, but is not limited to, information related to my/my minor child’s physical, behavioral, or mental health conditions previously disclosed.
If you have questions about the disclosure of the requested records, please contact Chestermere Lifepath Wellness, Ltd. at (403) 235-6208.
This request is for my minor child YesNo
Date
Printed Name
Signature:
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