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The Nozzle Forward & Aaron Fields Seminar Registration
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Medical Access Protection Safe
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This form has been modified since it was saved. Please review all fields before submitting.
Requestor(s) Name
*
Date of Request
*
Date of Request
Requestor's Address
*
Requestor's Phone Number
*
Requestor's Email Address
Emergency Contact Name
*
Emergency Contact Phone Number
*
Patient's Name
*
Patient's Phone Number
*
Installation Location Address
*
You will need to provide us a key to place in the safe
Other Information
Medical Information
*
Please be specific in listing medical conditions
Lease Fee
*
I understand that if i request a medical access protection safe, I will be charged a one-time fee of $25.00. This should be cash or check only.
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.
I agree.
Electronic Signature
*
You will be contacted by our Executive Assistant to confirm availability.
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