RapidLink Medical Group PC

YOUR INFORMATION

Your full legal name

Date of birth

Phone number

Attorney / law firm (if you know it)

YOUR SIGNATURE

Type your full legal name, then sign in the box with your finger or mouse. This one signature applies to all the forms above.

Type your full legal name Sign here

I certify that I have read and understood each form above, that I am the person named, and that my signature applies to all of them. I am 18 or older (or a parent/guardian signing for a patient 13 or older).

Thank you — your forms are signed.

Dr. Bakdash's office has received your signed consent forms. Please continue to the medical questions.