Patient Intake Form

TriMedical is providing a medical service to you and is committed to keeping your personal information confidential and secure.

It is important that you understand the purposes for the information we collect about you. In addition to the disclosures outlines in the Medical Assessment, it may be necessary to make additional disclosures of your information to other health care professionals, with your permission in order to complete the medical service TriMedical is providing to you. This may involve the release of information about your laboratory or diagnostic imaging results, evaluation or treatment.

By signing the consent statement below, TriMedical has your authorization to use and disclose your information for the purposes described. Additional consent will be required from you should any new purposes for your information be identified, in addition to those stated above.

Name

I herby authorize TriMedical to disclose my personal information (including personal health information) to other health care professionals for the purpose of testing, evaluation or treatment in addition to the disclosure outlined in the Medical Assessment.

First Name

Last Name

Today's Date

This consent applies to my visit as below.

MM

DD

YYYY

Consent

By submitting this consent form, I agree that I shall have no claim against TriMedical by reason of their disclosure of my personal information for the reasons stated above.

I agree

TriMedical Office

#102 - 12565 88th Avenue
Surrey, BC, V3W 3J7
Canada

Toll-free 236-862-2126