Consent for Release of Confidential Medical Information

1. Physical examination including urine dipstick
2. TB and blood tests (including, but not limited to Serum Pregnancy Test, CBC, CMP)
3. Copy of immunization records
4. Copies of current prescriptions currently being taken

The purpose of the disclosure authorized herein is to ensure the appropriateness of the wilderness treatment program and to ensure the safety of the above-named participant while enrolled in the wilderness treatment program.

Instructions to Practitioner/Medical Practice

1. 1. Complete physical form
   2. Complete required blood work (or make arrangements to have drawn at a lab)
   3. Complete the Physician’s Order form for PRN medications
   4. Fill out any additional prescriptions
   5. Fax results of physical, blood work, and prescriptions to Anasazi Foundation at 480-892-6701