How to Write
Step 1 – Download in PDF.
Step 2 – The first two (2) pages of the form contain important information that the patient should read before signing. Once you have read through the provided information and the agreement that you are making, if you wish to proceed, provide the following information at the bottom of the third page:
- Signature
- Printed name
- Complete address
- The date
Step 3 – You will also have to have a witness and, if you are under 21, a parent or guardian sign the document.