Living Springs Natural Health (LSNH) & Living Springs Health & Wellness (LSHW), PLLC are members under the:

TURTLE ISLAND PROVIDER NETWORK Licensed & Registered by: Tribal Health Programs & Clinics

A Private Tribal Membership Facility NOT OPEN TO THE PUBLIC

Permission to Discuss (Consult) Health Condition(s) and General Information

I, Enter Your Name., give the providers and/or employees of Living Springs Natural Health and Living Springs Health & Wellness, the right to discuss my case with other doctors or any other authorized representative(s) that I name below, (ie spouse, family members and/or friends of the above named individual).

Please list the names of all person(s) you give permission to discuss (include doctor(s) and family members):

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Please list any phone number(s) you will be comfortable for our office to leave any personal messages regarding your health, lab and other information:
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I further release the provider(s) and/or employees of the LSNH & LSHW from any consequences that may arise directly or indirectly from their discussion (consultation) with the above named or unnamed facility or any authorized or unauthorized representative of the above listed facility with regard to my medical conditions.

I understand, agree & provide my consent that the submission of this form electronically requires the use of a digital signature. By signing, I agree that my digital signature on this form has the same legal affect as my manual signature (in accordance with the ESIGN Act).

E-Sign Your Signature Here	Date: Select Today’s Date

Patient Signature

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Guardian Signature (if patient under 18yrs): Click or tap here to enter text.