Personal Intake Release Form

Please fill out the form below or download the personal intake release form with the button above and fill it out at your convenience. Please email us if you have any questions. You can send completed paper forms to:

403 W. Cool Dr.
STE 107
Tucson, AZ 85704

or fax to:


    *This is for family or friends only, there is a separate release for physicians.

  • MM slash DD slash YYYY
  • This is to Authorize:

  • To receive and/or discuss the following information with Southern Arizona Neuropsychology Associates: (Please check each box that applies)

  • This information is requested in case of an emergency, to allow psychological and/or financial access to an individual in addition to the patient (other than a physician), and/or in the event that our office is unable to speak with, or get in touch with the patient. By signing this document, the patient is releasing the right to disclosure of the specific information listed above. The patient is able to void this consent at any time by forwarding Southern Arizona Neuropsychology Assoc. a written request of nullification.

  • MM slash DD slash YYYY

By clicking the submit button, you authorize the transmission of your personal health information to be sent over email. We take every effort to ensure that your information stays safe. All information is double encrypted and password protected.