Student Wellness Centre
75 University Avenue West
Waterloo, Ontario N2L 3C5
T 519.884.0710 x3146
Authorization for Release of Information
Pursuant to the Personal Health Information Protection Act, 2004 (PHIPA)
Please ensure this form is fully completed. Once you complete and sign this form, it authorizes the
release of protected information.
Date of Birth:
Patient hereby authorizes the Student Wellness Centre at Wilfrid Laurier University to
Release information to
quest information from
Release the Follo
Please be as specific as possible about the information you would like released.
Blood / test results dated
Medical records. Please specify dates of visits or specific concern(s):
Counselling records. Specify dates of visits:
I hereby waive any and all claims against the physician
s and staff of the Student Wellness Centre in
connection with the disclosure of this personal health information.
Signature of Patient and Date
Signature of Witness and Date