AMENDMENTS BY AUTHORIZED REPRESENTATIVE

I am the legally authorized representative of the patient named above and have attached proof of that representation. I hereby request an amendment 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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