Alpha-1 Canadian Registry

RELEASE OF MEDICAL INFORMATION FORM

Participant's Name:
Date of Birth:
Address:
City:
Province:
Postal Code:	Home Phone Number:
E-mail Address:

Your doctor is your respirologist or your family doctor.
Doctor:
Address:
City:
Province:
Postal Code:	Doctor's Phone Number:

I authorize the release of medical information to: Alpha-1 Data Management Centre The Toronto Western Hospital Suite 4-011 Edith Cavell Wing 399 Bathurst St Toronto, Ontario M5T 2S8 Fax: 416-603-5020 or 416-603-0348 Signature:______________________________________________ Date:______________________