The Santa Barbara Institute for Medical Nutrition & Healthy Weight
Let Food Be Your Medicine Too!
Name:
Previous
Name
Date
of
Birth:
Tel.
No.:
Street
Address:
City:
State:
Zip
Code:
The specific information that I wish to have released is:
All Clinical Medical Records
Other Records - Please list (e.g. billing, angiograms, photos, etc.):
This medical record may contain information about physical or sexual abuse, alcoholism, drug abuse,
sexually transmitted diseases, abortion, or mental health treatment. Separate consent must be given
before this information can be released.
I consent to have the above information released.
I do not consent to have the above information released.
Signature:
Date:
(Parent or Legal Guardian of Minor)
This medical record may contain information concerning HIV testing and/or AIDS diagnosis or treatment.
Separate consent must be given to have this information released.
I consent to have the above information released.
I do not consent to have the above information released.
Signature:
Date:
(Parent or Legal Guardian of Minor)
I understand that this authorization is valid from the date signed. A photostatic copy of this authorization shall be
considered as effective and valid as the original. This authorization is subject to cancelation at any time by written
notice, but would not apply to any information already released.
Release Records to:
Name:
Tel. No.:
Street Address:
City:
State:
Zip
Code:
Medical Office and Appointments: 2403 Castillo Street, Suite 205 Santa Barbara CA USA 93105
805-569-7827voice 805.569.7828fax
www.DrJohnLaPuma.com
www.PediatricObesity.com
