Secure patient form

Privacy notice acknowledgement

Your records with our clinic are protected health information under HIPAA, and we only share them as the law allows or as you authorize. Our Notice of Privacy Practices explains how. You can ask for a copy at any time.

How the state registry protects your information is set by state law; the state program pages explain it.

Required

Patient

First name

Last name

Date of birth

Phone

Notice of Privacy Practices

How we may contact you

Optional. Tell us how you'd like to hear about your appointments.

You may contact me about appointments by

Phone call Voicemail message Text message Email

Anyone else we may speak to about scheduling your appointments

Name and relationship. Leave blank if there is no one.

Signature

Typing your full legal name here is your electronic signature.

Today's date

If you are signing for the patient, your relationship to them

For example, parent, legal guardian or personal representative.

Sent privately to our care team