To whom it may concern, We have asked your patient to see you because he/she is enrolled in the Life! program; a diabetes, heart disease & stroke prevention program delivered by AB Health and Fitness. This is a chronic disease prevention program and is delivered by Diabetes Victoria in partnership with AB Health and Fitness and is funded by the Victorian Department of Health and Human Services. This form is used to confirm that your patient gives consent for you, the treating health professional/s and/or health provider, to disclose relevant information to AB Health and Fitness. If more information is needed AB Health and Fitness may contact you, as the treating health professional/s and/or health provider, to confirm or clarify information provided. If you are contacted you may be asked to disclose medical and health information on behalf of your client. I hereby authorise and consent to my treating health professional/s and/or health provider, to release all relevant medical records relating to my enrolment in the Life! program. (Please put patient's complete name below)
*
Date of Birth (DOB)
*
Complete Address
*
Signature
*
Clear
Today's Date
*
Submit