Reinhardt University Student Health Services (Page 3 of 6) in pdf

Reinhardt University Student Health Services Page 3

Reinhardt University Health Clinic: Medical Information Release Form

Name: _______________________

DOB: ___________

Release of Information:

[ ] I, (name of student)______________, authorize the release of

information including the Health History/Immunization and clinic visit

records to:

[] Parent___________________________________________

[ ] Spouse__________________________________________

[ ] Other (Physician/Medical Practice/University/College

____________________________________________

[ ] Refusal to release any information.

This Release of Information will remain in effect until terminated by me in

writing.

Messages

Please call [ ] my home [ ] my work [ ] my cell

Number:__________________

If unable to reach me:

[ ] You may leave a detailed message

[ ] Please leave a message asking me to return your call

[ ] No messages

The best time to reach me is (day)___________________ between

(time)_________

Signed: ______________________________________

Date: ____/____/_____

Witness:______________________________________Date:

___/____/______

Reinhardt University Student Health Services Page 3