Type NA if the question does not apply to you.
Who does patient(s) live with?:
Legal guardian Information (if applicable) *please provide custody paperwork and photo ID*
If it doesn't apply you can type n/a
May we leave a message on voicemail with results?
May we send you a text messages?
Secondary insurance information
Please sign electronically below.
Click submit and you hereby give consent to sign this document electronically.