Address:
Flint
5417 Gateway Centre
Flint, MI 48507

Other Locations
Saginaw
Bay City

Phone:
(810) 424-0705 – Flint
(989) 401-6591 – Saginaw
(989) 892-9341 – Bay City

Hours:
Mon–Fri: 8:00 AM–5:00 PM

Contact Us

Document Signers

- 1 Patient

Print Document

When you click Print below we will prepare a printable document for you. It will automatically download when it's ready.

Did you know?
You can fill in the document online and then click the print icon and all of your information will be populated in the printable document, saving you time later.

SeamlessDocs

Create Your Signature

Please fill in your name and email and then either draw or type your signature below.

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Clear Signature

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

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Listed Signers

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Patient
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