CONSENT FOR RELEASE OF INFORMATION: INITIAL VISIT
I ______________________________ of _______________________ hereby consent
to ________________ breast screening service accessing any and all information contained
in my clinical (health) record retained by _____________________for the following purposes:
(1) for the Department of Health and Community Services to evaluate the effectiveness of Breast Cancer Screening Services in meeting its objectives and goals;
(2) for the Department of Health and Community Services to collect statistics on the early detection of and treatment of breast cancer in New Brunswick to determine whether or not breast cancer mortality is decreasing in the province; and
(3) utilization in the Canadian Breast Cancer Screening Database for research concerning breast cancer.
Signed by ________________________ day of ____________________ 199___.
