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Test for Patient Registration

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Your legal name

Your email address

Please Confirm full name and signature.

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Signed by Northern Virginia Pediatrics Admin
Signed On: June 9, 2022

Timestamp

Audit

June 1, 2022 12:36 PM EDT

Test for Patient Registration Uploaded by Northern Virginia Pediatrics Admin - michael@websubstance.com IP 173.79.171.24