Personal Information

 

EMERGENCY CONTACT INFORMATION

  • Please Select an answer for each question.

  • Your signature below indicates your consent for the treatment of/as patient and the release of medical information to your insurance company for claim purposes. I understand/acknowledge that any service charges which are deemed medically unnecessary or inappropriate by my insurance company will be paid directly by me.
 

ACKNOWLEDGMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICE

  • which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.
 

Verification