CANADA
PROVINCE OF ONTARIO
CITY OF HAMILTON, ONTARIO
TO: WHOM IT MAY CONCERN:
RE: IRREVOCABLE DIRECTION & AUTHORIZATION
RELEASE OF MEDICAL INFORMATION
AZIGA, Johnson
D.O.B.: June 6, 1956
YOU ARE HEREBY AUTHORIZED AND DIRECTED to release all information, reports,
clinical notes and records, opinions and diagnostic test results, and any other medical information.
or material touching upon my medical condition, in your possession, control or custody, which
may from time to time be requested from you, and in particular, regarding my HIV positive status,
and my viral load and ART medication I may from time to time be taking to control the virus.
Your full co-operation in this respect is respectfully requested,
YOU ARE FURTHER REQUESTED not to disclose any information to any other persons
without written authorization to do so.
DATED at Hamilton, Ontario, this 25" day of May, 2011
Ss
AZIGA, Johnson