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Confidentiality Statement

I attest the patient registration form is correct to the best of my knowledge. I also consent to treatment and consent to the confidentiality statement.

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Your legal name

Your email address

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

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Timestamp

Audit

June 12, 2019 9:07 am EDT

Patient Registration Signature Uploaded by Ajay Sood - drsood@drsoodmd.com IP 152.2.50.51

June 19, 2019 10:27 am EDT