Once you have filled out all of the required fields (highlighted in red) accurately, a box will appear on the left side of the screen with a yellow button to click to “Confirm Signing”.  If that box does not appear, then the required fields have either not been filled out correctly, or you have missed a place.  Please go back through the forms carefully to make sure that all fields are filled in according to the requirements.

NOTE: If you exit out of this form before clicking “Confirm Signing”, the document will not be saved.

If you need assistance with this form, please call 866-219-4318.

Please click on the blue link below if you are filling out our new patient evaluation for a child ages 2 months – 2 years.