Notice of Privacy Practices

I acknowledge that I have been providing with a copy of the Practice's Notice of Privacy Practices.

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RELEASE OF INFORMATION

CANCELLATION POLICY

Please call 24 hours in advance to cancel or reschedule your appointment. Failure to do so in less than 24 hours will result in an administration fee of $50 will be charged to your account and is due before further services are rendered.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

PRACTICE USE ONLY