Electronic Signature Consent

By typing your name and signing this form, you affirm that you have read this document, that you agree to the terms and conditions, and that you consent to sign this document electronically. You are not required to sign electronically and may request this document in non-electronic form. You have the right to withdraw your consent to further electronic disclosures, in writing, at any time. You have the right to receive a copy of your completed form. You may reach us by phone at (919) 600-4906, and our address is 115 Kildaire Park Dr Ste 313, Cary, NC 27518. If you are signing this document on behalf of a legal dependent (such as a minor child), you attest that you have the legal authority to sign on behalf of this patient without the approval of another person (such as a minor's other parent).