Your privacy and confidentiality are important to us.

St. George Medical Clinic, Inc. does not verbally release any information regarding medical care or test results to anyone other than the patient, unless otherwise authorized.

Please indicate below the name and relationship to you of the person (such as your spouse, mother, sister, etc.) to whom we may release such information if necessary. Otherwise, we will refuse any face-to-face or calls requesting this information. You may revoke this authorization in writing at anytime.

Note: We may use and disclose your health information as it relates to your treatment, payment for services, and our operations as indicated in our HIPPA Privacy Policy.

By signing this form, you authorize us to release verbally any information regarding your medical care or test results to the individual(s) named below.