Release Medical Info – Portland Ketamine Clinic Forms

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Release of Medical Information

Name*

First Last

Email*

I Authorize*

Name of Doctor/Therapist or Pain Specialist above and their Address Below

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Doctor/Therapist or Pain Specialist Phone Number*

Doctor/Therapist or Pain Specialist Fax Number*

Doctor/Therapist or Pain Specialist Email

To Release My Health Information to the Office of:

Portland Ketamine Clinic
Dr. Enrique Abreu, Dr. Danyi

Phone: (503) 207-4992
Fax: (503) 961-1859

Description of Information to be Disclosed*

All of my health information that the provider has in his or her possession including information relating to any medical history, mental or physical condition and any treatment received by me.

Only the following records or types of health information.

If Checked Option 2: List Records or Types of Health Information to be Disclosed

Type NA if not applicable

List Any Other Doctors/Therapists or Pain Specialists You Would Like to Authorize to Release Health Information

Signature Agreement of Patient or Legally Responsible Party*

Signature

Date*

If Legal Representative, Relationship to the Patient

Is There Anything Else You Would Like the Doctor to Know?

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Phone

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