top of page

DBA Signature Capture


The undersigned does hereby declare that all information given in this form or attached thereto is accurate and complete to the best of their knowledge and belief. In addition, the undersigned understands that failure to provide accurate & complete information may constitute insurance fraud thereby subjecting them to potential prosecution.

By signing below, I acknowledge that I have read and understand this release and authorize the release of my health information as described above. In addition, I understand that a photocopy of this form shall be as valid as the original.

Signatures Submitted!

bottom of page