Request a copy of my information.
We do need to have these requests in writing to send to you.
Name
*
First Name
Last Name
Email
*
example@example.com
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date
*
-
Month
-
Day
Year
Date
Which forms are you requesting a copy of?
*
Participant Waiver of Liability
Consent to Treat
Registration
Financial Policy
Financial Agreement
Audio Visual Release
Notice of Privacy Practices
Health History Form
Medication Tracking Form
Please send to me by:
*
Mailing Address listed above
Email Address listed above - with password setup
I understand by choosing to receive a copy of my forms by email they will come by encrypted email and will require a password setup to download.
*
Yes
I understand that forms requests are processed on the 1st and 15th of the month or the closest business day and then will take e-mail setup or mailing time for me to receive.
*
Yes
Signature
*
Clear
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: