Happy Girl Medical Delivery Service

Tel 1-416-824-5156·  Fax 416-542-1627  Membership Application

 mark@happygirl.ca   Patient Release and Diagnosis

Please make sure all information is printed clearly

Patient/Applicant Name: ___________________________________________________

Address: _______________________________________________________________

City: _________________   Prov: Ontario Postal: __________________

Home: _______________  Work: __________________    Cell: __________________

e-mail:__________________________________________ (Bday) D____ M____ Y____

I, the above named individual, consent the release of my medical information to Happy Girl.

Applicant Signature_____________________________

Has been diagnosed with: _________________________________________________.

Symptoms include:_______________________________________________________.

I understand my office will be contacted by telephone to confirm this information.

Doctors Signature________________________________