Personal Intake Form / Personal Release

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

Patient Name:(Required)

First Last

Date of Birth:(Required)

This is to Authorize:

Authorized Party's Name

First Last

Relation to Patient:

Phone#:

Authorized Party's Name

First Last

Relation to Patient:

Phone#:

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

Authorized to Receive/Discuss

Neuropsychological/Psychological report, diagnosis, and/or suggestions

Financial information/inquiries

Other

If you do not wish to release any information to anyone, please check the box below.

I do not authorize any other individual as a contact (beyond the HIPPA allowable).

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.

Client/ Guardian Signature(Required)

Date

Comments

This field is for validation purposes and should be left unchanged.

Personal Intake Form / Personal Release

This is to Authorize:

Hours

Contact Info

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