It’s Your World.

Your privacy and your comfortability is important to us! While we wish to help you in the best way we can, which may involve reaching out to other professionals for assistance, we will never share your personal information without your consent!

Name

First Name

Last Name

I allow the use and sharing of my protected health information as seen professionally fit by Resilience Fitness & Sports Performance.

I do

I do not

I authorize Resilience Fitness & Sports Performance Training to exchange or disclose or obtain my health information to this person &/or organization(s):

I understand and agree that this Authorization will be valid for one year from this date unless specified otherwise here. I understand that after that date or event, no more of this information can be used or released to the person or organization unless I sign a new Authorization like this one.