Written Acknowledgement Form
PLEASE INDICATE THE PHONE NUMBERS WHERE MESSAGES CAN BE LEFT.
PLEASE IDENTIFY THOSE PEOPLE YOU WISH TO HAVE ACCESS TO YOUR PROTECTED HEALTH INFORMATION:
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.