We are pleased to welcome you to our office. Please take a few minutes to fill out as completely as you can. If you have any questions we will be glad to help you.
Last Name
First Name
Date 10/22/2020
I have had full opportunity to read and consider the contents of the Notice of Privacy Practices. I understand that I am giving my permission to your use and disclosure of my protected health information in order to carry out treatment, payment activities, and healthcare operations. I also understand that I have the right to revoke permission.