By clicking submit, I hereby acknowledge and certify that I am authorized to disclose the
information above for purposes of providing my or my practice’s contact information and
preferences to 4th Trimester Care on behalf of myself or on behalf of the individual interested in
the program. I further understand that the information listed above will be disclosed to the 4th
Trimester Care staff to contact me about my patients who register for services provided by
4th Trimester Care.