This form will permit Health Services to release necessary medical information to a specific recipient.
Complete the form and submit by either:
(1) email: firstname.lastname@example.org
(2) fax: 416-971-2089
(3) drop off at Accounts Office in Health Services
Please note the fee must be paid before the request is processed:
If you are unable to view or print our forms, please visit or send someone on your behalf to our clinic to pick up a hardcopy.