Release of Information

Please print out this form (however many copies you need), fill it out, sign it and bring it to your appointment.

Thank you.

Candida Fink MD
New Rochelle NY 10801
(877) 534-1090

Consent To Release Information

I hereby give Dr. Fink permission to speak with the following individual/organization regarding...

Myself OR My Child (circle one)

Child's Name: ______________________ DOB: ____________________

Individual/Organization Name: ________________________________

Address: ________________________________________________

Telephone: ___________________________________

Dr. Fink may release written reports on the treatment and may receive written information from the above named individuals as well.

__________________________________________________
Patient Name

__________________________________________________
Patient Signature

__________________________________________________
Guardian Name/Relationship

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Candida Fink MD