HelloNote

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:

 

Discipline:

 

 

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

Leave this empty:

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Signature Certificate
Document name: HelloNote Electronic Signature Form
lock iconUnique Document ID: 9095420a0ea7214b44b2f8f1b78c075bd568fd62
Timestamp Audit
October 29, 2021 5:20 pm ESTHelloNote Electronic Signature Form Uploaded by HelloNote EMR - hello@hellonote.com IP 108.6.11.147