USA Top Docs Consent Form

Physician's Name(Required)


By providing and submitting my fax number and/or email addresses on this form I am giving USA Top Docs (and all of its subsidiaries), permission to use this information in perpetuity and from time to time send marketing related information via fax and/or email. I also acknowledge an ongoing business relationship with USA Top Docs. I understand that my information will never be sold or distributed to anyone outside of USA Top Docs. If I wish to be removed from USA Top Docs (or its subsidiaries) communication, I must submit the request in writing to [email protected], via fax to 908-288-7241 or via phone message by calling 908-288-7240 x 100 24/7/365. For this request to be valid (i) the request must clearly identify the fax number(s) to which this request relates too and (ii) the request must be communicated by one of the methods listed above.
By Checking This Box, I Am Signing This Application
Signed By (Name)