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Release of Information

Dear:

Fax Number:

I am currently a patient under the care of the midwives at Lincoln Community Midwives. I hereby request that my medical records (as outlined below) be released to Lincoln Community Midwives as soon as possible. The records you can provide will be invaluable. I thank you for your assistance in this matter.

I understand the purpose for disclosing this personal health information to the Lincoln Community Midwives. I understand that I can refuse to sign this consent form.

By filling out this form and clicking on "Submit", I am

Lincoln Community Midwives is a group of registered midwives providing primary care. We are fully funded by the Ministry of Health.

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