Acknowledgement of Receipt of Notice of Privacy Practices

The undersigned patient or parent/legal guardian of the patient acknowledges that they have been provided by Kidology Pediatrics, PLLC the notice of Privacy Policies on the date indicated below:

Name of patient(s)

Relationship to patient(s)

Do we have permission to leave a message such as appointment reminder, laboratory results or medication information on a voicemail or with a family member?

Yes No

Do we have your permission to leave a detailed message?

Yes No

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.

Signature

Date

Your information will be encrypted.