IWAMH-Clinic Policy and Agreement Form

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IWAMH-Clinic Policy and Agreement Form

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* Indicates required question

Patient's Name: *

Your answer

Patient's Date of Birth: (MM/DD/YYYY)
*

Your answer

Please select if you agree:
*

Yes, I agree that I have read and fully understand IWAMH's Clinic Policy and Agreement.

Please select: *

I am the patient.

I am the guardian or parent of the patient.

Your Printed Name: (as it appears on your ID or insurance ID) (Served as your e-Signature) *

Your answer

Guardian/Patient's Date of Birth: (MM/DD/YYYY) (Served as your e-Signature) *

Your answer

Date Signed: *

MM

/

DD

/

YYYY

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