I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform the doctor or other health professionals of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment.
When you select the button below, you will be taken to a screen to sign this document electronically. If you are unfamiliar with electronic signatures, please watch this short video.