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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.
Date of Request
Date of Request
Requestor's Phone Number
Requestor's Email Address
Emergency Contact Name
Emergency Contact Phone Number
Patient's Phone Number
Installation Location Address
You will need to provide us a key to place in the safe
Please be specific in listing medical conditions
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.
You will be contacted by our Executive Assistant to confirm availability.
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