Form YG4684 "Consent to Release Information" - Yukon, Canada

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Download Form YG4684 "Consent to Release Information" - Yukon, Canada

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CONSENT TO RELEASE INFORMATION
#2 Hospital Road
Whitehorse, Yukon, Y1A 3H8
I, ___________________________________________________, of ___________________________________________________
OWNER/OPERATOR/AGENT
NAME OF PREMISES
___________________________________________________________________________________________________________
ADDRESS OF PREMISES
hereby consent to the exchange of relevant information between Health and Social Services, Environmental Health
Services and _______________________________________________________________________________________________
___________________________________________________________________________________________________________.
All precautions to maintain the confidentiality of the information will be taken and no other persons will have access to it
without my further written consent except as required by law. The information will be used to assist the above-noted in
conducting business with you.
Y Y Y Y
/
M M
/
D D
This consent becomes effective ___________________________ and will be in effect for:
3 months
6 months
12 months
other ______________________________________________
This consent may be revoked by the undersigned at any time upon written notification to Health and Social Services,
Environmental Health Services. Should further information be required with regard to this consent please contact this
office at (867) 667-8391.
SIGNATURE OF OWNER/OPERATOR/AGENT
PRINT NAME
DATE SIGNED
WITNESS
PRINT NAME
YG(4684EQ)F1 Rev 02/2017
Print
Clear
CONSENT TO RELEASE INFORMATION
#2 Hospital Road
Whitehorse, Yukon, Y1A 3H8
I, ___________________________________________________, of ___________________________________________________
OWNER/OPERATOR/AGENT
NAME OF PREMISES
___________________________________________________________________________________________________________
ADDRESS OF PREMISES
hereby consent to the exchange of relevant information between Health and Social Services, Environmental Health
Services and _______________________________________________________________________________________________
___________________________________________________________________________________________________________.
All precautions to maintain the confidentiality of the information will be taken and no other persons will have access to it
without my further written consent except as required by law. The information will be used to assist the above-noted in
conducting business with you.
Y Y Y Y
/
M M
/
D D
This consent becomes effective ___________________________ and will be in effect for:
3 months
6 months
12 months
other ______________________________________________
This consent may be revoked by the undersigned at any time upon written notification to Health and Social Services,
Environmental Health Services. Should further information be required with regard to this consent please contact this
office at (867) 667-8391.
SIGNATURE OF OWNER/OPERATOR/AGENT
PRINT NAME
DATE SIGNED
WITNESS
PRINT NAME
YG(4684EQ)F1 Rev 02/2017
Print
Clear