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.
Medical History Access-Provides the physician with information about medications the patient is already taking to minimize the number of adverse drug events.
By typing your name below, you are agreeing that Blue Ridge Pediatrics, LLP can request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payers for treatment purposes. You also agree your electronic signature is the legal equivalent of your manual signature on this application.
FOR BLUE RIDGE PEDIATRICS’ USE ONLY
Your information will be encrypted.