ࡱ> ;  2!"#$%&'()+,-./01456789:<=Root Entry( JrsMatOST  sxsMMMN0 ND  FMicrosoft Office Word Document MSWordDocWord.Document.89quST  6=/8d ,t6HTMatadorObject0 F s sOle 1TableCompObjq@@@ NormalCJ_HaJmH sH tH DAD Default Paragraph FontRiR  Table Normal4 l4a (k(No Listr#$LMNpqt@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0r r r k:(DTi2Sk@rp@UnknownGz Times New Roman5Symbol3& z ArialK@Palatino Linotype"h{fVTvr4dqq2QHX)?2OlePres000 OlePres001RWordDocument 4SummaryInformation( */ )winspoolCanon i550 (Copy 1)Ne02: ;$4    V ."System ’9$ -@Times New Roman-  2 ZQ D- 2 Q D-{@Palatino Linotype-;2 r( Q Patient Information Release FormPC+'@M,!-N,I5uC+(IM!Y@'@C8@!JI5v 2 r Q DT 2 &Q DT@Palatino Linotype-+2 Q I ___________________e"2222222222222222222d2 ;Q _____ consent to the release of all medical information on 22222,7:*0:!!7!:0(/02*07!2X0>,2:"7(X2!7:7:2 >RQ file at the White Crane Clinic, as well as, any verbal clarification of Physician !02!!:0d:!0G(2:0G;,2*S02*2:890(72,2(",2"7:7!<:8+-2:V2 2Q notes, diagnosis and treatment method, or prescrip:7!0*=28:7+*2;=!(02!X0:!X0!:7=6(<'0*,(<52 Q tion related information to "7:(02!0=;!7(X2!7:!7;2 K Q _______________________________.2222222222222222222222222222222O2 K'-Q This consent can be cancelled in writing at =;*,7;+0:!,2:70,2;,00=:S(":82!2 MQ anytime by the patient and will be effective as of the date of the signature.2:8!X078!:0<2!0:!2:=T700"!0,"902+7!!:0=2!07!!:0*8:2!<(0 2  Q D> 2 YQ D? 2 Q D?L2 g+Q _________________________ Patient Signaturet2222222222222222222222222<2!0:!58:2!<)0 2 gQ D? 2 g4Q D,,2 g` Q _________________ Date22222222222222222M2!0 2 g Q D?2 Q ___2222 SQ ______________________ Witness _________________ Datea2222222222222222222222d!:0+*22222222222222222M2!0 2  Q D? 2 uQ D? 2 Q D?2 lQ ------------------------------------------------------------------------------------------------------------!!!"!!!"!!"!!"!!!"!!"!!"!!!"!"!!!"!!!"!!"!!"!!!"!!"!!"!!!"!"!!!"!!!"!!"!!"!!!"!!"!!"!!!"!"!!!"!!!"!!"!!"!!!! 2  Q D@ 2 Q D?.2 Q Cancellation of ConsentG2:,02!7:7!G7:*1:! 2 !Q D? 2  Q D?@2 #Q _________________________ Patient S2222222222222222222222222<2!0:!52 Q ignature8:2!<)0 2 Q D? 2 4Q D,,2 ` Q _________________ Date22222222222222222M2!0 2 Q D?2 % VQ _________________________ Witness _________________ Date2222222222222222222222222d!:0+*22222222222222222M2!0 2 % Q D? 2 Q D? 2 3 Q D?-NANI ;$4;$4    V ."System ’9$ -@Times New Roman-  2 ZQ - 2 Q -{@Palatino Linotype-;2 r( Q Patient Information Release FormPC+'@M,!-N,I5uC+(IM!Y@'@C8@!JI5v 2 r Q T 2 &Q T@Palatino Linotype-+2 Q I ___________________e"2222222222222222222d2 ;Q _____ consent to the release of all medical information on 22222,7:*0:!!7!:0(/02*07!2X0>,2:"7(X2!7:7:2 >RQ file at the White Crane Clinic, as well as, any verbal clarification of Physician !02!!:0d:!0G(2:0G;,2*S02*2:890(72,2(",2"7:7!<:8+-2:V2 2Q notes, diagnosis and treatment method, or prescrip:7!0*=28:7+*2;=!(02!X0:!X0!:7=6(<'0*,(<52 Q tion related information to "7:(02!0=;!7(X2!7:!7;2 K Q _______________________________.2222222222222222222222222222222O2 K'-Q This consent can be cancelled in writing at =;*,7;+0:!,2:70,2;,00=:S(":82!2 MQ anytime by the patient and will be effective as of the date of the signature.2:8!X078!:0<2!0:!2:=T700"!0,"902+7!!:0=2!07!!:0*8:2!<(0 2  Q > 2 YQ ? 2 Q ?L2 g+Q _________________________ Patient Signaturet2222222222222222222222222<2!0:!58:2!<)0 2 gQ ? 2 g4Q ,,2 g` Q _________________ Date22222222222222222M2!0 2 g Q ?2 Q ___2222 SQ ______________________ Witness _________________ Datea2222222222222222222222d!:0+*22222222222222222M2!0 2  Q ? 2 uQ ? 2 Q ?2 lQ ------------------------------------------------------------------------------------------------------------!!!"!!!"!!"!!"!!!"!!"!!"!!!"!"!!!"!!!"!!"!!"!!!"!!"!!"!!!"!"!!!"!!!"!!"!!"!!!"!!"!!"!!!"!"!!!"!!!"!!"!!"!!!! 2  Q @ 2 Q ?.2 Q Cancellation of ConsentG2:,02!7:7!G7:*1:! 2 !Q ? 2  Q ?@2 #Q _________________________ Patient S2222222222222222222222222<2!0:!52 Q ignature8:2!<)0 2 Q ? 2 4Q ,,2 ` Q _________________ Date22222222222222222M2!0 2 Q ?2 % VQ _________________________ Witness _________________ Date2222222222222222222222222d!:0+*22222222222222222M2!0 2 % Q ? 2 Q ? 2 3 Q ?-q` r bjbjqPqP 4::r ( @@@@@@@@xzzzzzzh? *z@@@@@z@@@@@@@@x@@x@@@@4 s@@x0@i @i @i @8@@@@@@@@zz@@@@@@@@d  Patient Information Release Form I ________________________ consent to the release of all medical information on file at the White Crane Clinic, as well as, any verbal clarification of Physician notes, diagnosis and treatment method, or prescription related information to _______________________________. This consent can be cancelled in writing at anytime by the patient and will be effective as of the date of the signature. _________________________ Patient Signature _________________ Date _________________________ Witness _________________ Date ------------------------------------------------------------------------------------------------------------ Cancellation of Consent _________________________ Patient Signature _________________ Date _________________________ Witness _________________ Date "$9q r hkOJQJhhkOJQJhkCJ OJQJaJ hhkCJ OJQJaJ hk#$ L M N  p q r $a$gdkgdkr 21h:pk/ =!"#$% Oh+'0`    ( 4@HPXNormal2Microsoft Office Word@D|@S@re@4pDocumentSummaryInformation83CompObjU՜.+,0 hp|   q  Title  {w{   qq ! MOMO!! Times New Roman =/8=/8d ( JrMicrosoft Works MSWorksWPDoc9q