Consent for collection of health info

Consent for the Collection Personal Health Information
I, blanks* , have reviewed the BrightStar Care written statement concerning the collection, use and disclosure of personal health information.
Patient Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Marketer Name

First NameLast Name
Marketer Email
example@example.com
Should be Empty:

Consent for the Collection Personal Health Information