Instructions:

IMPORTANT: Please be sure to choose the "DRAW" option for your signature, which allows you to use your finger to sign your actual signature - many medical providers require this.

We recommend that you use your mobile phone or tablet device to fill out this form, as many find it easier to sign using a finger rather than using a mouse.

In the section "Relationship To Patient", if you are the patient/injured party, simply type "self" in that box. If you are filling it out for someone else, type your relationship to the Patient.