I hereby give consent to Lincoln University Student Health Center where I received care from _________________ to _________________ to release the information to:

(Name of Institution/Person)                                                          (Phone Number)

________________________________________________                   _____________________________

(Street Address)                                                                          (Fax Number)

(City)                                                                              (State)            (Zip Code)

(Patient Signature)                                                                  (Social Security Number)

___________________________________________                       ________________________________

(Print Name)                                                                            (Date of Birth)

________________________________________________               _________________________________                                          

(Witness Signature)                                                                (Today’s Date)