Pharmacist Records Release — page 11 Enter the pharmacist and receiving contact information. Your signature is placed on the release and on any media permission you grant. Pharmacist name Receiving contact name Contact telephone Fax number Photo / video permissionLeave unansweredGrant permissionDecline permission Special images showing treatment or health statusLeave unansweredGrant permissionDecline permission Client / authorized signerChoose signature methodType signatureDraw signature Type full name Draw signatureClear signature Date signed
Facility Authorization — page 12 Enter the facility name and the person or organization receiving the information. Facility name Information released to Photo / video permissionLeave unansweredGrant permissionDecline permission Special images showing treatment or health statusLeave unansweredGrant permissionDecline permission Client / authorized signerChoose signature methodType signatureDraw signature Type full name Draw signatureClear signature Date signed
Physician Authorization — page 13 This is the second physician authorization form included in the source packet. Physician name Receiving contact name Contact telephone Fax number Client / authorized signerChoose signature methodType signatureDraw signature Type full name Draw signatureClear signature Date signed
Emergency Contact Authorization — page 14 Enter the information recipient. Photo permissions remain separate choices. Information released to Photo / video permissionLeave unansweredGrant permissionDecline permission Special images showing treatment or health statusLeave unansweredGrant permissionDecline permission Client / authorized signerChoose signature methodType signatureDraw signature Type full name Draw signatureClear signature Date signed