8/18/2019 Authorization for Release of Records Copy

1/1

Dr. Amy Dobbie, NDNaturopathic Doctor

The World of My Baby - The WOMB388 Main St E

Milton, ON L9T 1P8Tel: 905-842-2434 Fax: 905-842-2434

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AUTHORIZATION FOR RELEASE OF RECORDS FROM HEALTH CARE PROFESSIONAL TO THEWORLD OF MY BABY

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Section 1:(Patient to complete Section 1 and 3 of this form)

To: Dr. ____________________________

Fax No#: ___________________________

Address: ______________________________________________________________

___________________________________

Telephone:__________________________

From: Patient:_______________________

Date of Birth: _______________________

Address: ___________________________

___________________________________

___________________________________

Telephone:__________________________

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Section 2:

Health Records _______________________________________

Laboratory Results _______________________________________

Imaging Results _______________________________________

Other _______________________________________

PLEASE SEND THE FOLLOWING REPORTS WITH THE SIGNED FORM

___________________________________________________________________________

Section 3:

I _________________________________ give permission to receive / send the above listed

reports on my behalf. I release from you all legal responsibility or liability that may arise from

this authorization.

Signature of patient: ____________________________________

Date: ____________________________________

Erica Robinson

416-913-1236

400 Bronte Street South Suite 205

Milton ON L9T 0H7

905-876-3047