If you are at least 18 years old and would like to give another person (example: spouse, sibling, child, parent) permission to discuss your test results, appointment schedule, or treatment with Take 2 Healthcare staff, please fill out the information below.

I give my permission for Take 2 Healthcare doctors and staff to freely discuss all health information, test results, recommendations and future health concerns with .

If I choose to rescind permission for above person to discuss my health status and results, I understand that I must submit this request in writing to Take 2 Healthcare.