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
2 digit month, 2 digit day, 4 digit 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
Other
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
*
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: