This form is not submitted online.  Please print, fill out, and return to the office. 

Candida Fink MD

12 Parcot Ave

New Rochelle NY 10801

Phone 877-534-1090  Fax 914- 560-2106

CONSENT TO RELEASE INFORMATION

DATE: __________

Patient Name: ____________________________________________________

Date of Birth: ____________________________________________________

Parent or Guardian if appropriate_____________________________________

By signing this form I give consent for Dr. Fink to communicate with the following individuals or organizations regarding medical care of the above named patient.

Individual/Organization Name: ________________________________________

Address: _______________________________________________________

City: ________________________ State: ______________ Zip: ____________

Telephone: _______________________   Fax: _____________________________

Communication methods may include US Post Office or other delivery services, voice/telephone, fax, secure email, and other electronic formats. You may request or restrict specific methods of communication.

This agreement will remain in effect while patient is under dr. Fink’s care , unless it is  rescinded by patient/representative.  In all other circumstances the agreement will expire one year from the date indicated above

Patient/Guardian Name (printed)_________________________

Patient Guardian Signature_____________________________   Date________