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AUTHORIZATION TO DISCLOSE VERBAL HEALTH INFORMATION The Holier Psychiatric Group Peter Thomas, PhD 4510 Medical Center Dr., Suite 208 McKinney, TX 75069 Office: 4697420199 Fax: 9725424106 Patient

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2. Start by writing your full name in the designated space at the top of the form.
3. Move on to providing your contact information, including your phone number and email address.
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5. Proceed to enter your medical history, including any current conditions or medications you are taking.
6. If applicable, indicate any allergies or known drug sensitivities.
7. Additionally, provide any relevant family medical history if requested on the form.
8. Complete any remaining sections of the form, such as insurance information or emergency contact details.
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