Medium

Available on

Apple Android Windows

Medical Release Mobile App

This app is a great replacement for your office's medical release forms. It can be tailored to included any additional verbage you may want to include. The signature capture feature allows the patient to sign digitally on any mobile device.

  • Lendlease
  • The Cooperative
  • PG&E
  • oxy
  • Red Bull
  • Mirvac

Want to learn more about GoCanvas?

Request a Demo

Take a peek inside the Medical Release Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    Choose One (Elegir Uno)

  • Ico checkbox

    I would like to complete the form in English

  • Ico checkbox

    Me gustaría completar el formulario en Español

  • Ico statictext

    Authorization letter for the release of employee medical record information to a designated repre...

  • Ico statictext

    I,

  • Ico textbox

    (full name of worker/patient)

  • Ico statictext

    hereby authorize

  • Ico textbox

    (individual or organization holding the medical records)

  • Ico statictext

    to release to

  • Ico textbox

    (individual or organization authorized to receive the medical information)

  • Ico statictext

    , the following medical information from my personal medical records:

  • Ico multiline

    (Describe generally the information desired to be released).

  • Ico multiline

    I give my permission for this medical information to be used for the following purpose:

  • Ico statictext

    but I do not give permission for any other use or re-disclosure of this information.

  • Ico multiline

    (Note: Several extra lines are provided below so that you can place additional restrictions on t...

  • Ico textbox

    Full name of Employee or Legal Representative

  • Ico signature

    Signature of Employee or Legal Representative

  • Ico date

    Date of Signature

  • Ico statictext

    Muestra de carta de autorización para la liberación de registros médicos del trabajador a un repr...

  • Ico statictext

    Yo,

  • Ico textbox

    (nombre completo del trabajador/paciente)

  • Ico statictext

    por este medio autorizo a

  • Ico textbox

    (individuo u organización en posesión de estos registros médicos)

  • Ico statictext

    a entregar a

  • Ico textbox

    (individuo u organización autorizada a recibir información médica)

  • Ico statictext

    , la siguiente información médica de mis registros médicos personales:

  • Ico multiline

    (Describa en forma general la información que desea sea liberada).

  • Ico multiline

    Doy mi permiso para que esta información médica sea usada para el siguiente propósito:

  • ...and More!

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