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Intake Forms Acknowledgement - eSignature

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Client Name:

Client Date of Birth:

Person Signing this form is: Client Parent/Guardian

Name of Person Signing this Form:

I attest that I have reviewed and understand the forms in this document, as listed below:

I agree to the information contained in each form to which I have attached my initial, attestation, or signature.

SIGNATURE:

If applicable:

MNCarePartner Staff:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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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

Timestamp

Audit

August 30, 2021 2:21 pm CDT

Intake Forms Acknowledgement - eSignature Uploaded by Roots Recovery - rootsforms@mncarepartner.com IP 206.84.188.12