Vireo patient kiosk
Capture release / consent signature
Sign here with mouse / stylus / finger
Relationship of signator to client
Client
Guardian
Legal Representative
Other
Parent
Physician
Plan executor
Witness
Name of signator(required)
Name of client associated with (required if relationship is not Client)
By signing this document, you agree to allow the agency to send your information anywhere they need to send it so they can get paid.
I agree
Clear