Electronic Health Data Sharing Consent Form
Patient Information
Full Name
Date of Birth
Contact Number
Email Address
Recipient Information
Name of Organization/Provider
Purpose of Data Sharing
Type of Information to be Shared
Medical History
Laboratory Results
Medications
Imaging & Radiology
Other
Consent Duration
Start Date
End Date
Consent Statement
I authorize the sharing of my electronic health data as specified above to the stated recipient for the purpose described. I understand that I may withdraw this consent at any time by notifying the provider in writing.
Patient Signature
Date
Provider/Witness Signature
Date