Authorization to Release Information to Family Members

    Many of our patients allow family members such as their spouse, significant other, parents or children to call and request the result of tests, procedures, and financial information. Under the requirements for Personal Health Information Protection Act (PHIPA) we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your medical information, any diagnostic test results and/or financial information released to any family members you must sign this form.

    You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.

  • NameRelation to Patient 
    (Click the + to add lines)
  • Authorization Regarding Messages (please check all that apply)

  • This field is for validation purposes and should be left unchanged.
Ottawa Valley Denture Clinic
186 Pembroke Street West,
2nd Floor
Pembroke, ON K8A 5M8