Authority to Release & Obtain Information Hidden{date_created:time} I,(Required) First Last Of address: Consent(Required) I agree to the belowINFORMED CONSENT- authority to obtain and release information relative to workplace rehabilitation services To commence and/or maintain ongoing in-person services you acknowledge you: Provide consent for CorpFit to release and/or obtain medical and other information considered relevant to my treatment. Have been provided with written information as to how CorpFit may collect and use my personal information. Throughout the program, should you have concerns or questions about any recommended treatment, you must inform the therapist immediately so rationale for treatment and/or adjustments to your treatment can be made. It is your responsibility to participate in all aspects of the program as it is imperative to its success. You agree to this consent remaining valid until such time as consent is withdrawn. I have read the information above and understand the reasons why my information must be collected, and the purposes for which my information may be used or disclosed. I understand that if my information is to be used for any purpose other than that set out above, my further consent will be obtained.Signature(Required)