Acknowledgement of Receipt and Requested Restrictions

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.

Patient Name:

Patient Date of Birth:

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.

SIGNATURES:

Patient/Legal Representative:

Date:

If Legal Representative, relationship to Patient:

Your information will be encrypted.