Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
To Whom It May Concern:
I give permission for Davidson Family Medicine, P.A. to discuss information pertaining to my care to the following individuals:
Name
Relationship
1.
2.
3.
4.
Digital Signature Authorization:
*
I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Patient Signature
Submit
Should be Empty: