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.
We need the name of someone we can contact in the event of an emergency as well as release medical information about your condition. Please list below.
PLEASE NOTE: If you are the PARENT OF A MINOR CHILD, you should be listed here as well as anyone else we may contact.
Please present insurance card(s) and photo ID to the receptionist to be scanned.
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.