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HelloNote Electronic Signature Form

I, , hereby authorize the use of the below signature as my
legal digital signature for physical, occupational, or speech therapy documents created by me on
HelloNote (E Medical Records Live Inc.)

Name:

State License #:

NPI #:

Email:

Clinic Name:

Clinic City, State:

User Type:

Therapist

Therapist Assistant

Student

Discipline:

SLP

Below, sign your normal signature size sign as close to your real signature as possible:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In 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

Adopt & Sign

Timestamp

Audit

October 29, 2021 5:20 pm EST

HelloNote Electronic Signature Form Uploaded by HelloNote EMR - hello@hellonote.com IP 100.38.101.240