Name:

Address:

City:     State/Province:

Zip/Postal:     Country:

Tel: (H):      (O):   (C):

e-mail:

Date of birth: (mm/dd/yyyy)

I, , hereby consent to Winnick Patient Advocacy (WPA),

Scott J. Winnick, and his/ its employees, contractors, consultants and other parties who require such information to assist us with establishing, maintaining and managing our relationship with you, to sharing, disclosing, and releasing any personal, health care, or other information to any party WPA/ Scott J. Winnick deem(s) appropriate, in order to assist myself, my spouse, or my family.

This information may be communicated via electronic or other means across State/ Provincial, Federal and International boundaries.

Signature

(typing your name on above line is equivalent to Signature of Client/ Guardian/ Authorized Representative and signifies your agreement to the above statement)

Date: (mm/dd/yyyy)

Witness’ typed name (equivalent to signature):

Date:   (mm/dd/yyyy)

Name:

Address:

City:     State/Prov:

Zip/Postal:  Country:

Tel:

e-mail: