Doctor Office/Name: ALABASTER PEDIATRICS
Address: 1004 1ST STREET NORTH, SUITE 370 ALABASTER AL 35007
Phone: 205-663-5547
Fax: 205-663-1990
This authorization shall be in effect until the information has been forwarded as requested or until the course of treatment is complete.
Patient Rights:
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Revised June 2016
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use: