BIRI Consent

Please review the BIRI Consent Form and submit the following Acknowledgment of Agreement.
Please print, sign and send to us.
This form must be submitted prior to us accepting your case.
Clicking "AGREE" below means that you AGREE and that you will print/sign/send the two forms to us ASAP. Fax or scan and attach to email is acceptable.

Acknowledgment of Agreement & Consent*
- I disagree.
- I agree.
By submitting "I agree", you are agreeing by digitally signing the BIRI INFORMED CONSENT and MEDICAL & LIABILITY Release Forms located at:
http://biri.org/pdf/forms/BIRI_Consent_Form.pdf
Digital Signature*
Type your name as you normally sign documents.
Name*
First Last
Date*
Date Format: MM slash DD slash YYYY
Email*
Enter Email Confirm Email