Patient Name *

First Name

Last Name

Visitor Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Confidentiality Agreement

I will respect the privacy of all patients in this treatment environment. I will not disclose the identity of any patient in the Cedars’ facility, nor will I fail to keep confidential anything seen or heard while on the Cedars’ property. It is essential to remember while talking with family or friends about your treatment experience that you only share information about your own experience and not reveal the identity or experience of a fellow patient. The staff at Cedars may be obligated to breach confidentiality in accordance with federal and provincial laws. I agree to abide by the terms of this agreement.

By checking this box, you acknowledge and agree to uphold the terms of this confidentiality agreement, serving as your digital signature.

Date *

MM

DD

YYYY