RELEASE OF PERSONAL INFORMATION

RELEASE OF PERSONAL INFORMTION

Name

Address

Phone

Date of Birth

Manitoba Health Card

Manitoba Health Card (9-digit number)

I give Dr. Reece Malone Permission to Release my Private Information

Yes No

Designated Recipient name

Recipient's address

Recipient's phone number

Recipient's fax (optional)

By typing my name, I hereby electronically sign this document your full name

The named individual(s) and offices(s) are authorized to exchange information and are hereby released from any legal liability that arises as a result of the exchange of information.

Date today's date

Note: This waiver is in effect for one year from the date of the request. Personal information is protected by the Personal Health Information Act and Protection of Privacy provisions of The Freedom of Information and Protection of Privacy Act.

Have a question? Just ask below. To book an appointment, click the 'Book Now' button

All matters related to sex, sexuality, and gender are welcome for discussion. Expect to be met with dignity, respect, compassion and full permission to speak what’s on your mind… authentically.

This is a sex and gender aware, affirming, and inclusive practice.

RELEASE OF PERSONAL INFORMTION

Have a question? Just ask below. To book an appointment, click the 'Book Now' button

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