Release Of Information

"*" indicates required fields

Authorization to Release Client Information

By signing below, I am authorizing Allmond Wellness to release my information to or obtain my information from:

Name of person/organization your would like Allmond Wellness to exchange information with*

First Last

Address of person/organization you would like Allmond Wellness to exchange information with*

Street Address Address Line 2 City State ZIP Code

Phone number of the person/organization*

Relationship to client*

Any limitations on this exchange?*

***This authorization will expire once you are no longer a client at Allmond Wellness or at any other time you designate***

Client Name*

Witness Name*

Date