I, (Please input Name below), give Dr. (Please input Doctor's Name below)
permission to contact the following provider(s) regrading my child's current medical care or medical history for the purpose of coordination of care.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Add New Provider
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use:
Copyright © 1999-2024 Hush Communications Canada Inc.