Consent For Release Of Information Form Page 2
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7Children’s & Women’s Health Centre of BC
DEPARTMENT OF PATHOLOGY & LABORATORY MEDICINE
Division of Laboratory Genetics
CONSENT FOR RELEASE OF INFORMATION
All fields must be completed legibly (patient demographics label acceptable).
Patient Name (Last, First):____________________________________
Date of birth (dd/Mmm/yy): __________________________________
PHN: ____________________________________________________
The Freedom of Information and Protection of Privacy Act of British Columbia prohibits the
disclosure of personal information outside of Canada without your explicit consent. Personal
information, held by any testing site located outside of Canada, is potentially subject to disclosure
demands under the local legal requirements of the country in which the testing site resides.
A test has been ordered by your physician, which will be performed at a testing site outside of
Canada.
In order to test the sample and report the results to the ordering physician, the following personal
information must be provided with the sample: Patient Name, Date of Birth and Personal Health
Number. Brief clinical information relevant to test interpretation may also be provided.
A sample, and the above stated personal information, will be sent to the following testing site:
__________________________________________________
Laboratory /Institution
__________________________________________________
Address
I hereby consent to the transfer of a sample and the release of the defined personal information
stated above, to the testing site named above, for the purpose of performing testing on the sample.
Person giving consent:
______________________________
_______________________________
Name (Print)
Signature for consent
______________________________
_______________________________
Relationship to patient
Date signed
PRINT FORM
Document # CWMG_REQ_0210C Version 2.1 Revised: July 2014
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