CONSENT FORM

/CONSENT FORM
CONSENT FORM 2017-10-19T04:29:39+00:00

Please complete the patient consent form below

  • Notice of privacy Act Acknowledgement Form

    This form is used to obtain acknowledgment of receipt of our notice of privacy practices or to document our good faith effort to obtain that acknowledgment. Signing of this form means you agree with the terms of our privacy practices. You may refuse to sign this form however, we reserve the right to refuse services.

  • (If patient is under the age of 18 a parent or guardian must sign.)
  • YOU MAY REFUSE TO SIGN THIS ACKNOWLEDGMENT

    Below this line for office use only

  • (If patient is under the age of 18 a parent or guardian must sign.)