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Medical Access Protection Safe

  1. You will need to provide us a key to place in the safe

  2. Please be specific in listing medical conditions

  3. Lease Fee*

  4. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your medical information is confidential and protected by physician-patient privilege, 2) I waive the physician-patient privilege relating to the authorization for release of my confidential medical information, 3) I understand that I may revoke this authorization any time after written notice except to the extent that prior action has been taken on the basis of this authorization, 4) I further understand that this information may be disseminated over the police and/or fire radio system and that the general public utilizing the proper radio receiving equipment can hear these radio transmissions, 5) your application will not be signed in the sense of a traditional paper document, 6) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 7) you may still be required to provide a traditional signature at a later date.

  5. You will be contacted by our Executive Assistant to confirm availability.

  6. Leave This Blank:

  7. This field is not part of the form submission.