By signing below, you acknowledge that you have received the Notice of Privacy Practices, Notice of Separate Practices and No Show/Late Cancellation Policy prior to any service being provided to you by the Practice, and you consent to the use and disclosure of your medical information as set forth herein except as expressly stated below.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use: