Authorization Form

You will be asked to sign a document indicating your approval:

1. to allow Dr. Vallentyne to perform a physical examination and
2. to allow Dr. Vallentyne to release his report to the person who requested the evaluation. 

If you have a lawyer, please review this release form with your legal representative prior to the appointment.

Authorization for Examination & Release of Information

I, ____________________________ , authorize Dr. Vallentyne:

1. to interview me and to physically examine me AND
2. to release a report based on the interview and examination to the agency or person that requested the independent medical examination.

_________________________             ________________________

(signature)                                                      (witness)

_________________________              ________________________

(date)                                                              (location)