DFS - Clients - Authority to Release Information

Note: Please complete a new copy of this form for each individual you wish to authorise.

Nearest DFS Clinic: *

Participant Name *

Participant Date of Birth *

give

Practitioner / Case Manager *

and other personnel of Direct Focus Solutions involved in the management and/or provision of services to me permission to:

Release information; and / or
*

Discuss elements of my case with:
*

Authorised Person *

Participant / Parent / Guardian Name *

Relationship to Participant(If required)

Participant / Parent / Guardian Signature *

Draw signature|Type signatureClear

Date *

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