Authorization For Release (Disclosure) Of Patient(s) Health Information

Please correct the errors described below.

Patient's Name

Date of Birth

Your information will be encrypted.

Loading...

Electronic signature

Your browser does not support capabilities required for electronic signatures.

Close

Loading templates...

Use existing signature
Type the signature
Draw
Upload an image

Click a signature you want to use:

Drop image file here or click to select file Click here to select image file from your computer

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Use this signature or Cancel

Hushmail

Copyright © 1999-2024 Hush Communications Canada Inc.

Terms of service
Privacy policy

Hide