Student Wellness Centre
75 University Avenue West
Waterloo, Ontario N2L 3C5
T 519.884.0710 x3146
F 519.885.4865
wellness@wlu.ca
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.
Patient Information
Name:
Laurier ID:
Address:
Health Card:
Date of Birth:
Laurier email:
Authorization
Patient hereby authorizes the Student Wellness Centre at Wilfrid Laurier University to
Release information to
Address:
Phone: Fax:
Re
quest information from
Address:
Phone: Fax:
Release the Follo
wing Information
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:
Other:
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
X
Signature of Witness and Date
