Request to Access the Personal Health Record

Request to Access the Personal Health Record

Parent/Legal Guardian
Information and Instructions

Lansdowne Children's Centre will provide access to a client’s personal health record, unless a legal exception applies. We will review all health record access requests and will make every effort to respond to requests in a timely fashion. Please be advised that consent from all legal guardians listed on a child’s file must be obtained before release of records. If all legal guardians reside at the same address: 1 form can be completed and signed by both legal guardians. If legal guardians are not at the same address: This form will need to be completed and submitted by all legal guardians for approval unless a legal exception applies.
For information about our Privacy Plan, contact us at: 39 Mount Pleasant Street Brantford, ON N3T 1S7
Phone- Main: (519) 753-3153 Fax: (519) 753-5927
Email: info@lansdownecc.com
Lansdowne Client Informaiton
Client Name

First NameLast Name
Client Date of Birth

MonthDayYear
Date
Client Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Requestor Information
Name

First NameLast Name
Relation to Child
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Do all legal guardians for this child reside at the same address?
Please describe information required and include details that will assist us in locating the information (e.g. dates, names of healthcare providers, etc.)
Please specify the method of delivery in which you prefer to receive this information:

Electronic Signatures
Name of 1st Legal Guardian

First NameLast Name
Signature of 1st Legal Guardian
Name of 2nd Legal Guardian

First NameLast Name
Signature of 2nd Legal Guardian
Should be Empty: