EFS Usage Waiver Form-Oasis Family Medical CTR

EFS USAGE WAIVER AGREEMENT
I, the undersigned, acknowledge, represent and agree that:

(Checking the box indicates that you agree with the following statements)
*
*
*
*
*
*

Salutation (Optional)
Mr., Mrs, Ms, Dr.,
First Name*
First Name
Middle Initial
Middle Initial (Optional)
Last Name*
Last Name
Suffix
Suffix (Optional)
Please select*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:*
E-mail*
Today's Date*

MonthDayYear
Signature of First Time EFS User or Guardian's Signature*
E-mail me a copy at:

Should be Empty: