FOR
A
LL P
A
TIENTS!
Please complet
e and sign both bo
xed areas on this pa
ge.
Your treatment and rec
overy will be optimized if
So
u
t
h
Ci
t
y
Ph
y
s
i
o
t
h
er
ap
y
has your permis
sion to share
information regarding your treatment, progress, and condition. To that end, we ask tha
t you sign the
Sharing of Medical Information –
Consent
Fo
rm
below. You are not obligated to provide this cons
ent,
and you may change or withdraw consent at any time in the future.
Sharing of
Medical Information –
Consen
t Form
I hereby authorize
So
u
t
h
Ci
t
y
Ph
y
s
i
o
t
h
er
ap
y
to give
treatment details, results, reports, and any other
relevant medical information, or material
to
the following;
(Please
initial each line y
ou authorize and prov
ide contact names a
nd phone numbers
w
here po
ssible)
Initials
Contact Name
Contact Phone #
My Family Physici
a
n
My Specialist / Surgeon
My Employer / Superv
isor