By signing this document, I acknowledge that I have received a copy of VALLEY PEDIATRICS' Notice of Privacy Practices.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
-OR-
-OR- Patient - Hospital - Physician Directory - Family Member - Friend - Newspaper - Yellow Pages
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
give Valley Pediatrics, P.C. permission to call this
with any test results or reports and leave a message on a voicemail or answering machine if no one answers.
I will notify Valley Pediatrics, P.C. if there is a change in the above phone number.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
I give Valley Pediatrics, P.C. permission to release my medical information to my parents.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Select one - If YES, please explain
Your information will be encrypted.