PLEASE NOTE: This form requires your electronic signature. Use your mouse, finger, or stylus to sign in the space provided.
By signing below, I understand and acknowledge the above information and consent to and agree to proceed with any treatment proposed. I acknowledge that I have been advised of my financial obligations to San Fernando Community Health Center including copays, deductibles and any anticipated denials for products furnished by the clinic. I also certify that I was given an opportunity to ask questions and all of my questions have been satisfactorily answered.