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2. Requestor(s) Name*
3. Date of Request*
   Date of Request
5. Requestor's Address*
7. Requestor's Phone Number*
8. Requestor's Email Address
10. Emergency Contact Name*
12. Emergency Contact Phone Number*
14. Patient's Name*
16. Patient's Phone Number*
18. Installation Location Address*
    You will need to provide us a key to place in the safe
20. Other Information
22. Medical Information*
    Please be specific in listing medical conditions
24. Lease Fee*

    1. 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.
26. 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.

    1. I agree.
28. Electronic Signature*
31. You will be contacted by our Executive Assistant to confirm availability.
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field