EHN Canada - Records Request Form

You indicated that you are completing this request on behalf of the client. Please provide your details below.
Applicant full name *

First NameLast Name
Applicant phone number *
Please enter a valid phone number.Format: (000) 000-0000.
Applicant email address *
example@example.com
Applicant Mailing Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
ConsentPower of Attorney (POA)Substitute Decision Maker (SDM)Court orderExecutorOther
Upload proof of authority*

Cancelof

Records requested
Date range of records requested (from – to)*
Programs / locations involved (if known)
Describe the records you are requesting (Please be as specific as possible to assist processing.) *
Encrypted and password‑protected emailOther
I understand a fee estimate may be requested before records are released.
Initials*

EHN Canada Records Request Form