Consent to Disclose

"*" indicates required fields

I,*

First Last

Authorize

Name of InspireHealth employee:*

To disclose my information consisting of:*

Describe the information to be disclosed.

To:*

Name and contact information of persons and/or organizations receiving the information.

For the purposes of:*

For what purpose is InspireHealth disclosing this information.

Consent Validity Period (How long will this consent be valid for):*

3 months from the date of signature

6 months from the date of signature

12 months from the date of signature

Other

I understand that I can withdraw this consent at any time.

Until this specific date (dd/mm/yy):*

I understand that I can withdraw this consent at any time.

Name*

First Last

Phone*

Email*

Address*

Street Address Address Line 2 City Province Postal Code

E-signature*

Date*