Consent Form A - ADHD & Autism Clinic

Consent to share my information with others

Name(Required)

First Last

Address(Required)

First line of address Address Line 2 City Postcode

Date of birth(Required)

dd/mm/yyyy

Mobile number(Required)

Name(Required)

First Last Relationship

Is there any information that you do not wish to share?

For example, you may be willing for information about your treatment to be shared, but you may not wish information about your personal history to be shared.

Yes

If (yes) please provide the information below

Signature