File Release Consent Form

Name: Little Lake Family Eye Care
Address: 11 Lakeside Terrace #102, Barrie, ON, L4M 0H9, CA
Telephone: 705-503-3937

Today's Date (mm/dd/yyy)*
MM slash DD slash YYYY
Name*
First Last
Date of Birth (mm/dd/yyyy)*
MM slash DD slash YYYY
From : Clinic name or Doctor's name*
Clinic Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Clinic Phone Number
Consent
I hereby consent to have my files released to Little Lake Family Eye Care.
Signature
Please fax files to 705.503.3938 or email to littlelakefamilyeyecare@gmail.com

Please fax files to 705.503.3938 or email to littlelakefamilyeyecare@gmail.com