FormlastupdatedJanuary2020
1
StudentConsentregardingPersonalHealthInformation
ThisformistobecompletedbyaregisteredQueen’sstudentreceivingcarefromStudentWellnessServices(SWS).A
signedformprovidesconsentforSWStoreceiveand/ordisclosepersonalhealthinformation,asspecified.
BOTHSIDESOFTHEFORMMUSTBECOMPLETED
StudentName:___________________________________________________________________________________
StudentNumber:________________________________DateofBirth(MM/DD/YYYY):____________________
Studentphonenumber:__________________________HealthCard#:_________________________________
Fillouteitherorbothboxes:
ConsentforSWStoDISCLOSEinformation ConsentforSWStoRECEIVEinformation:
Ifconsentisforspeakingtoaperson,consentiseffectivefrom(date)________________________________
to________________________________(date).Pleaseturnoverandsign
IauthorizeStudentWellnessServicestodisclose:
Mycompletemedicalrecord
Specifichealthinformationrelatedto:(detail)
__________________________________________
To(nameofindividual/organization):
__________________________________________
Contactinfo(Phone,Fax):
__________________________________________
Relationshiptostudent(ifapplicable):
__________________________________________
Forthepurposeof(ifapplicable):
__________________________________________
__________________________________________
IauthorizeStudentWellnessServicestoreceive
(Fax:6135336740):
Mycompletemedicalrecord
Specifichealthinformationrelatedto(detail):
From(nameofindividual/organization):
Contactinfo(phone,Fax)
_______________________________________________
Relationshiptostudent(ifapplicable):
Forthepurposeof(ifapplicable):
_______________________________________________
_______________________________________________
FormlastupdatedJanuary2020
2
Iunderstandhowtheinformationthatissharedwillbeusedbythereceivingparty.
StudentSignature:_________________________________________________________________________________
Date(MM/DD/YYYY):______________________________________________________________________________
WitnessName(pleaseprint):
________________________________________________________________________________________
WitnessSignature:_________________________________________________________________________
Date(MM/DD/YYYY):______________________________________________________________________
StudentWellnessServices
CôtéSharpStudentWellnessCentreandGregoryDavidandNeilRossyHealthPromotionHub
MitchellHall‐69UnionSt.W.
Queen'sUniversity
Kingston,ON
K7L3N6
Phone: 6135332506
Fax: 6135336740
Web: www.queensu.ca/studentwellness
PersonalinformationonthisformiscollectedpursuanttothePersonalHealthInformationProtectionAct,2004
(PHIPA).

click to sign
signature
click to edit
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome