Acknowledgement of Receipt of HIPAA Notice of Privacy Practices Consent to Treat

I acknowledge that I have received a copy of Personalized Pediatrics HIPAA Notice of Privacy Practices.

I hereby authorize Personalized Pediatrics to render medical treatment to my child as they deem necessary.

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.

Patient Name

Parent/Guardian Printed Name

Parent/Guardian Signature

Date

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