Medical Exercise Forms

Clients Only

Please fill out the appropriate functional scale assessment and tally your score:

Assessment Form

Release of Information

Please furnish to Sheryl Teitelbaum Oeftering (hereinafter facility noted in form and/or any of its personnel), information, copies of any and all hospital and medical records or reports of any sort, charts, notes, x-rays, lab reports and prescription information, including the right to inspect and copy such records. Facility is to be furnished any and all other information without limitation pertaining to any confinement, examination, treatment or condition of myself, including medical, dental, psychological or other treatment, examinations, or counseling for any condition, medical, dental or psychological.

 

This AUTHORIZATION shall be considered as continuing and you may rely upon it in all respects unless you have previously been advised by me in writing to the contrary. It is expressly understood by the undersigned and you are hereby authorized with the same validity as though an original had been presented to you.

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