EMERGENCY CONTACT INFORMATION
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.
By signing below, I understand that if I so choose, the individuals or agencies I have listed will be given access to my PROTECTED HEALTH INFORMATION from Associated Pediatricians, LLC.
CHOOSE FROM THE FOLLOWING:
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use:
Copyright © 1999-2022 Hush Communications Canada Inc.