Consent to Release Information Form ‘To ensure the client is able fo make an infarmad decision about consent a the disclasure ‘of their intarmation, the service provider/arganisation should: | ‘Give client information about privacy policy. (¥ tick when completed) C1 _—_Gve client a copy of this torm Please refer to the Guidelinas far halp in completing this form. 1(a) Person with epilepsy: DATE OF NAME ane sx OmOr ADDRESS PHONE EMAL 1(b) If person with epilepsy is under the age of 18 or has a guardian include details of the parent/guardian giving consent: NAME RELATIONSHIP ADDRESS PHONE EMAL 2 Agency/Service Provider/Health Professional requesting consent: NAME POSITION ‘ORGANISATION ADDRESS PHONE FAX EMAL