Patient Consent Form

    Patient's Legal Name:
    Date of Birth:

    I give the following individual(s) permission to speak on my behalf. They are allowed access to my billing information and/or medical records (for example: to schedule/cancel appointments, billing questions/payments, request for prescription refill, discuss biopsy results, etc.). I understand that I can add or remove anyone from this list at anytime by filling out another consent form.

    Name:
    Relationship:
    Type of Access Allowed:
    For How Long?

    Name:
    Relationship:
    Type of Access Allowed:
    For How Long?

    Name:
    Relationship:
    Type of Access Allowed:
    For How Long?

    Enter captcha here:

    Patient Signature:
    Date: