Johns Creek Pediatrics
I hereby consent to the release of my medical/billing records to the following person(s):
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
You may revoke or change this consent in writing at anytime.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use:
Copyright © 1999-2020 Hush Communications Canada Inc.