The undersigned hereby authorizes and requests:
Goodman Pediatrics, LLP
500 Helendale Rd, Suite 200
Rochester, NY 14609
To release information contained in patient’s medical records for the purpose of documentation to:
The authorization shall expire twelve (12) months from the date signed.
By typing your name above, 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 © 1999-2022 Hush Communications Canada Inc.