CROSSPARK MEDICAL, PLLC
200 West , 86th Street Suite 1i
New York, NY 10024

CONSENT TO DISCUSS MEDICAL
CONDITION/ INFORMATION WITH OTHER INDIVIDUALS

I, __________________________, give, Crosspark Medical, PLLC’s staff and physicians permission to
discuss my medical condition/ information either the individuals listed below. I understand that this
consent may be revoked at any time by notifying Crosspark Medical, PLLC’s in writing of my intent.

Name __________________________ Relationship to Patient _____________________________

Name __________________________ Relationship to Patient _____________________________

Name __________________________ Relationship to Patient _____________________________

Name __________________________ Relationship to Patient _____________________________

Name __________________________ Relationship to Patient _____________________________

Name __________________________ Relationship to Patient _____________________________

Signed: _________________________ Date___________________________________