Medical Release Form

View our HIPPA Notice

Authorization to Obtain/Release Confidential Medical Information

Patient Details

Patient Name:

Date:

Date of Birth:

Phone:

I authorize North Shore Nutrition Consultants, LLC to share my progress and health care information with medical professionals and the following individuals.

Primary Care Physician

Name:

Address:

Phone:

Referring Physician/NP/PA

Name:

Address:

Phone:

Specialist (Cardiologist, Endocrinologist, Allergist, etc.)

Name:

Address:

Phone:

Mental Health Therapist

Name:

Address:

Phone:

Other

Name:

Address:

Phone:

I understand that my records and treatment is confidential. They will not be disclosed without my consent. I understand I may revoke this consent at any time.

I Agree

First Name:

Last Name:

Email:

Confirm Email