I, (print name of physician)
am of the opinion that the disclosure, transmittal or examination of the record of personal health information or the following part of the clinical record, namely:
complied in (name of psychiatric facility)
in respect of (print full name of patient)
harm to the treatment or recovery of the said patient, or injury to the mental condition of a third person, or bodily harm to a third person
(signature of physician)
Date(day/month/year)
6435-41 (04/11)
7530-4980