EHN Canada - Records Request Form
Language
  • English (Canada)
  • French (Canada)
  • EHN Canada Records Request Form

    Please complete the following section with the information of the client whose records are being requested.
  • Client's Date of Birth
     - -
  • Format: (000) 000-0000.
  • Please select the facility where services were provided:*
  • Are you the client whose records are being requested?*

  • You indicated that you are completing this request on behalf of the client. Please provide your details below.

  • Format: (000) 000-0000.
  • How are you authorized to request these records?*
  • Browse Files
    Drag and drop files here
    Choose a file
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  • Records requested

  • Consent & Certification

  • Clear
  • Date Signed*
     - -
  • Client Signature Date*
     - -
  • Should be Empty: