diff --git a/app/components/clinic/PatientForm.js b/app/components/clinic/PatientForm.js
index c1bd83c799..366c6d8cb6 100644
--- a/app/components/clinic/PatientForm.js
+++ b/app/components/clinic/PatientForm.js
@@ -11,10 +11,12 @@ import { Box, BoxProps } from 'rebass/styled-components';
 
 import * as actions from '../../redux/actions';
 import TextInput from '../../components/elements/TextInput';
+import Checkbox from '../../components/elements/Checkbox';
 import { getCommonFormikFieldProps } from '../../core/forms';
 import { dateRegex, patientSchema as validationSchema } from '../../core/clinicUtils';
 import { accountInfoFromClinicPatient } from '../../core/personutils';
 import { Body1 } from '../../components/elements/FontStyles';
+import baseTheme from '../../themes/baseTheme';
 
 export const PatientForm = (props) => {
   const { t, api, onFormChange, patient, trackMetric, ...boxProps } = props;
@@ -69,9 +71,11 @@ export const PatientForm = (props) => {
 
   function getFormValues(source) {
     return {
+      attestationSubmitted: get(source, 'attestationSubmitted', false),
       birthDate: get(source, 'birthDate', ''),
       email: get(source, 'email', ''),
       fullName: get(source, 'fullName', ''),
+      id: get(source, 'id'),
       mrn: get(source, 'mrn', ''),
     };
   }
@@ -149,6 +153,25 @@ export const PatientForm = (props) => {
       <Body1>
         {t('If you want your patients to upload their data from home, you must include their email address.')}
       </Body1>
+
+      {!patient?.id && (
+        <Box
+          p={2}
+          mt={3}
+          mb={2}
+          bg="lightestGrey"
+          sx={{
+            border: baseTheme.borders.default,
+            borderRadius: `${baseTheme.radii.default}px`,
+          }}
+        >
+          <Checkbox
+            {...getCommonFormikFieldProps('attestationSubmitted', formikContext, 'checked')}
+            label={t('I attest that I have obtained permission from the patient and/or the patient\'s legal guardian to use Tidepool\'s software to assist in the management of the patient\'s health care.')}
+            themeProps={{ bg: 'lightestGrey', lineHeight: 1.4 }}
+          />
+        </Box>
+      )}
     </Box>
   );
 };
diff --git a/app/core/clinicUtils.js b/app/core/clinicUtils.js
index f1515c1e91..b6f38e5be5 100644
--- a/app/core/clinicUtils.js
+++ b/app/core/clinicUtils.js
@@ -1,6 +1,7 @@
 import * as yup from 'yup';
 import get from 'lodash/get';
 import includes from 'lodash/includes';
+import isEmpty from 'lodash/isEmpty';
 import keys from 'lodash/keys';
 import map from 'lodash/map';
 import moment from 'moment';
@@ -137,6 +138,7 @@ export const clinicSchema = yup.object().shape({
 });
 
 export const patientSchema = yup.object().shape({
+  id: yup.string(),
   fullName: yup.string().required(t('Please enter the patient\'s full name')),
   birthDate: yup.date()
     .transform((value, originalValue) => {
@@ -148,4 +150,9 @@ export const patientSchema = yup.object().shape({
     .required(t('Patient\'s birthday is required')),
   mrn: yup.string(),
   email: yup.string().email(t('Please enter a valid email address')),
+  attestationSubmitted: yup.mixed().notRequired().when('id', {
+    is: id => isEmpty(id),
+    then: yup.boolean()
+      .test('isTrue', t('Please confirm that you have obtained this permission'), value => (value === true)),
+  }),
 });
diff --git a/package.json b/package.json
index 155735921f..e93b923a26 100644
--- a/package.json
+++ b/package.json
@@ -1,6 +1,6 @@
 {
   "name": "blip",
-  "version": "1.53.1-web-1577-date-format.1",
+  "version": "1.53.0-web-1495-patient-form-attestation",
   "private": true,
   "scripts": {
     "test": "TZ=UTC NODE_ENV=test ./node_modules/karma/bin/karma start",
diff --git a/test/unit/app/core/clinicUtils.test.js b/test/unit/app/core/clinicUtils.test.js
index a676d3f5cd..b855b31fd0 100644
--- a/test/unit/app/core/clinicUtils.test.js
+++ b/test/unit/app/core/clinicUtils.test.js
@@ -133,13 +133,15 @@ describe('clinicUtils', function() {
   });
 
   describe('patientSchema', () => {
-    it('should return a yup schema for clinic fields', () => {
+    it('should return a yup schema for clinic patient fields', () => {
       expect(clinicUtils.patientSchema).to.be.an('object');
 
       expect(clinicUtils.patientSchema._nodes).to.be.an('array').and.have.members([
-        'fullName',
+        'attestationSubmitted',
         'birthDate',
         'email',
+        'fullName',
+        'id',
         'mrn',
       ]);
     });
diff --git a/test/unit/pages/ClinicPatients.test.js b/test/unit/pages/ClinicPatients.test.js
index 8cc9e9d290..acee05a68b 100644
--- a/test/unit/pages/ClinicPatients.test.js
+++ b/test/unit/pages/ClinicPatients.test.js
@@ -402,6 +402,10 @@ describe('ClinicPatients', () => {
       patientForm().find('input[name="email"]').simulate('change', { persist: noop, target: { name: 'email', value: 'patient@test.ca' } });
       expect(patientForm().find('input[name="email"]').prop('value')).to.equal('patient@test.ca');
 
+      expect(patientForm().find('input[name="attestationSubmitted"]').prop('checked')).to.be.false;
+      patientForm().find('input[name="attestationSubmitted"]').simulate('change', { persist: noop, target: { name: 'attestationSubmitted', value: true } });
+      expect(patientForm().find('input[name="attestationSubmitted"]').prop('checked')).to.be.true;
+
       store.clearActions();
       dialog().find('Button#addPatientConfirm').simulate('click');
 
@@ -469,6 +473,10 @@ describe('ClinicPatients', () => {
       patientForm().find('input[name="email"]').simulate('change', { persist: noop, target: { name: 'email', value: 'patient@test.ca' } });
       expect(patientForm().find('input[name="email"]').prop('value')).to.equal('patient@test.ca');
 
+      expect(patientForm().find('input[name="attestationSubmitted"]').prop('checked')).to.be.false;
+      patientForm().find('input[name="attestationSubmitted"]').simulate('change', { persist: noop, target: { name: 'attestationSubmitted', value: true } });
+      expect(patientForm().find('input[name="attestationSubmitted"]').prop('checked')).to.be.true;
+
       expect(dialog().find('Button#addPatientConfirm').prop('disabled')).to.be.true;
 
       patientForm().find('input[name="birthDate"]').simulate('change', { persist: noop, target: { name: 'birthDate', value: '11/21/1999' } });
diff --git a/test/unit/pages/ClinicianPatients.test.js b/test/unit/pages/ClinicianPatients.test.js
index 235edeb5e6..5c86df65e2 100644
--- a/test/unit/pages/ClinicianPatients.test.js
+++ b/test/unit/pages/ClinicianPatients.test.js
@@ -196,6 +196,10 @@ describe('ClinicianPatients', () => {
       patientForm().find('input[name="email"]').simulate('change', { persist: noop, target: { name: 'email', value: 'patient@test.ca' } });
       expect(patientForm().find('input[name="email"]').prop('value')).to.equal('patient@test.ca');
 
+      expect(patientForm().find('input[name="attestationSubmitted"]').prop('checked')).to.be.false;
+      patientForm().find('input[name="attestationSubmitted"]').simulate('change', { persist: noop, target: { name: 'attestationSubmitted', value: true } });
+      expect(patientForm().find('input[name="attestationSubmitted"]').prop('checked')).to.be.true;
+
       store.clearActions();
       dialog().find('Button#addPatientConfirm').simulate('click');
 
@@ -260,6 +264,10 @@ describe('ClinicianPatients', () => {
       patientForm().find('input[name="email"]').simulate('change', { persist: noop, target: { name: 'email', value: 'patient@test.ca' } });
       expect(patientForm().find('input[name="email"]').prop('value')).to.equal('patient@test.ca');
 
+      expect(patientForm().find('input[name="attestationSubmitted"]').prop('checked')).to.be.false;
+      patientForm().find('input[name="attestationSubmitted"]').simulate('change', { persist: noop, target: { name: 'attestationSubmitted', value: true } });
+      expect(patientForm().find('input[name="attestationSubmitted"]').prop('checked')).to.be.true;
+
       expect(dialog().find('Button#addPatientConfirm').prop('disabled')).to.be.true;
 
       patientForm().find('input[name="birthDate"]').simulate('change', { persist: noop, target: { name: 'birthDate', value: '11/21/1999' } });