"*" indicates required fields Patient Name* First Last Date of Birth* Month Day Year If you would like to delegate another individual to have unrestricted access to your medical record and the information contained therein please provide the information in the space provided below. This permission is also revocable with written request from you at any time.* I do not wish my medical information to be released to any significant other. I request and authorize Arizona Allergy Associates to review and release my medical information to the following individuals (e.g. Spouse, Parent, Sibling, etc.) HiddenName* First Last Relationship* Phone Number*Name First Last Relationship Phone NumberName First Last Relationship Phone NumberName First Last Relationship Phone NumberHiddenWe can leave a message with voice messages can you meet the following people: detail at home with a family member or in your voicemail?* Yes No Voicemails may be left with the following people to:Name* First Last Relationship* Phone Number*Name First Last Relationship Phone NumberName First Last Relationship Phone NumberName First Last Relationship Phone NumberSignature* Type name for signature.Today's Date* Month Day Year PLEASE NOTE* This authorization will remain in effect until it is revoked in writing.Consent* By clicking submit I agree that I have read and will abide by all of Arizona Allergy Associates policies and that all information provided is accurate. Additionally, I acknowledge that this will serve as my electronic signature. Δ