Union Mill Pediatrics, P.C.
I authorize the release of my child(ren)’s medical records to:
Union Mill Pediatrics, P.C.:
Dr. Maura Eriksson
Dr. Wayne Eriksson
Dr. Shoshana Killian
Dr. Pooja Dhananjayan
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use:
Copyright © 1999-2023 Hush Communications Canada Inc.