4. Clinical Guidelines for Liver Transplantation (PDF) - British ...

Guidebook for the Solid Organ Transplant Programme Chapter 4
AUTHORIZATION FOR RELEASE OF INFORMATION
Re: ____________________________________________________________
(Name of Patient-Print in Full)
(Date of Birth)
Address of Patient: ______________________________________________________
I, _____________________________________________, do hereby authorize you to
permit __________________________________to release the following information:
(Name of institution)
Appendix K
(Note approximate dates in hospital and indicate what specific information the records are required)
_______________________________________________________________________
_______________________________________________________________________
to, BC Transplant:
I consent to the use of this information by the authorized recipient only for the purposes of:
____________________________________________________________
I am nineteen years of age or older.
Dated this _______________________________day of__________________, 20____
Signature: _______________________ Witness: _______________________
(Patient)
(Signature of Witness)
_______________________
(Print Name of Patient)
________________________
(Print Name of Witness)
_______________________
(Parent or Guardian)
Address of witness if not an employee of BC Transplant:
________________________________________________________________________
________________________________________________________________________
Relationship to Patient: __________________________________________________
Chapter 4 – Clinical Guidelines for Liver Transplantation – July, 2010 Page 55
See Page 1 for disclaimer