Medical Release Form

View our HIPPA Notice

Authorization to Obtain/Release Confidential Medical Information

Patient Details

I authorize North Shore Nutrition Consultants, LLC to share my progress and health care information with medical professionals and the following individuals.

Primary Care Physician

Referring Physician/NP/PA

Specialist (Cardiologist, Endocrinologist, Allergist, etc.)

Mental Health Therapist


I understand that my records and treatment is confidential. They will not be disclosed without my consent. I understand I may revoke this consent at any time.