MEDICAL RELEASE CONSENT FORM

Name*
Please complete this form to confirm that you agree to the release of your results to a third party.

I hereby give permission for The London General Practice to disclose the results of my Test to:
First Name Last Name
Email
Full Name of Patient
First Last
Date of Birth*
DD slash MM slash YYYY
Please acknowledge
- By typing my signature below I agree to be legally bound by this document.
Signature
Email*
Phone*
If Under 18...
Parent / Guardian Name:
First Name Last Name
Relationship to Patient:
Please acknowledge
- By typing my signature below I agree to be legally bound by this document.
Parent / Guardian Signature:
By typing your signature below you agree to be legally bound by this document.
First
Date
MM slash DD slash YYYY