ACCESS BY AUTHORIZED REPRESENTATIVE
I am a legally authorized representative of the patient named above
and have attached proof of that representation. I hereby request
access to the patient’s personal records on his or her behalf.
Authorized representative’s contact information
Mr / Mrs / Ms (please circle) Street address: _____________________________________
Last name:__________________________________ City /town: ______________________________
Prov.______
First name: _________________________________ Postal code: ___________________
Fax:_________________
Health card number: ______ ___________________ Tel: (home) _____________________
(bus) _________________
Date of birth (dd/mm/yy): ______________________ Email address:
_______________________________________
X______________________________________ _________________________________________
Authorized Representative Signature
Date (dd/mm/yy)
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