You are on page 1of 1

I(WAZULU.

NATAL PROVI NCE


HEALTH
REPUBLIC OF SOUTH AFRICA

MAHATMAGAND@
Ofiice of the Medical Manager
Address : Private Bag X 13, Mount Edgecombe' 4i100

031 502 17919 Fax:086 575 6612 Email address: nancy.bridgemohun@kznhealth'govza

ooNSENTToPRoVIDEINFoRMATIoNToATHIRDPARTY

tx ft mn-rl-
I, r.l xt F.ll S.-i*l trcL Sq3 ( G;; Jpatient / legal-guardran/ er<eeuter) hereby
f\ (relationshiP to Patient
consent to the release of mY I mY
) L\ r )

of attendance/ diagnosis or other:


medicar information/ copy of hospital records/ dates
L LCJ dI- ? (sPecifY) 16 S n ' \'r u'r'L t oar'-; J (third
rn C0(q
party).

NAME: S " ,^n L-l J --lt t -aJ ra-(l- srcNAru RE #$A{


DATE: )ot>i .*\,,

WITNESSES:
( ou eJ o c-L
1, NAME: M SIGNATURE;

2. NAME: SIGNATURE:

GROWING KWMULU-NATAL TOGETHER

You might also like