THE CANADIAN COLLEGE OF NATUROPATHIC MEDICINE
AUTHORIZATION FOR RELEASE OF RECORDS FROM HEALTH CARE PROFESSIONAL TO NATUROPATHIC DOCTOR
Fax: 905.893.2423
(Please fax this form back with the records)
To: Dr.: From: Patient:
(please print) (please print)
Fax No#: Date of Birth:
Address: Address:
Telephone: Telephone:
PLEASE SEND THE FOLLOWING REPORTS WITH THE SIGNED AUTHORIZATION FORM
X-Rays __________________________________________
Blood Test Results __________________________________________
Other __________________________________________
On my behalf, I _____________________________ give my permission to receive/send
the above listed reports to Dr. _________________, ND. I release from you all legal
responsibility or liability that may arise from this authorization.
Signature of patient:
Date:
Naturopathic Doctor (please print) Lic #
Signature of ND________________________________________
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
Related searches
- college of medicine tucson
- does naturopathic medicine work
- doctor of naturopathic medicine schools
- doctor of naturopathic medicine program
- american association of naturopathic physicians
- directory of naturopathic physicians
- american association of naturopathic medicine
- doctor of naturopathic medicine online
- doctor of naturopathic medicine degree
- structure of the canadian government
- accredited schools of naturopathic medicine
- american association of naturopathic doctors