Information Release Form
I authorize Minnesota Voice & Speech Clinic to consult, exchange diagnostic
and therapy information with the following professionals regarding:
Client’s Name:______________________________DOB:_______________
| Name | Initial & Date | |
| Orthodontist | ___________________________ | _________________ |
| Dentist | ___________________________ | _________________ |
| Physician | ___________________________ | _________________ |
| Allergist | ___________________________ | _________________ |
| ENT | ___________________________ | _________________ |
| School SLP | ___________________________ | _________________ |
| Insurance(s) | ___________________________ | _________________ |
Signature: _____________________________________ Date: ___________
Relationship: ___________________________________________________