Electronic Signature Permission Form

Electronic Signature Permission Form
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Parent/Caregiver's Name*

First NameLast Name
Email*
example@example.com
I hereby give permission for Therapy West to use my signature to sign future DSL’s until my child is discharged or otherwise notified.

Caregivers/parents retain the right to review/revise DSLs upon request. Caregivers/parents may also revoke this permission at any time by submitting in writing.
Signature*

Clear
Date Signed

MonthDayYear
Date
Should be Empty: