Due to patient confidentiality, Circle of Wellness staff are unable to discuss any aspect of a patient’s medical file with anyone other than the patient, without written consent.  The only exceptions to this policy is if the patient has a Power of Attorney, or the patient is 17 years of age or younger in which case all communication would be with the parent/guardian. 

If you would like to give consent for someone(s) else to be able to discuss your medical records with Circle of Wellness staff, the form below must be filled out. 

** DISCLAIMER: Should circumstances change, it is the responsibility of the patient to amend this form by contacting Circle of Wellness.  It is also the responsibility of the patient to update Circle of Wellness regarding who can access and discuss specific areas of your medical record as outlined in the form.  Circle of Wellness and all entities within Circle of Wellness bears no responsibility for any subsequent consequences should these details not be kept up to date by the patient.  **