Please click on any services that you would like our friendly staff to discuss with you during your visit:

Have you ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic.)

Have you ever had any of the following? (Please check all that apply)

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES AND CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

Notice of Private Practices: You have the right to read our Privacy Practices before you decide whether or not to sign this consent. A copy of our Notice and/or this consent is available upon request. Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we make of your protected health information.

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. I have been shown a copy of this office’s Notice of Privacy Practices and have had full opportunity to read and consider its contents. I understand that by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.

In addition to allowable disclosures described in the statement of Privacy practices, I hereby specifically authorize disclosure fo my Protected Healthcare information to the person(s) identified below. (I understand the default answer in "NO" without indicating "YES" in answer to each individual question personal protected information cannot be shared with anyone unles otherwise allowed by HIPAA rules.)

By placing my name and date below, I acknowledge that I have read and understand the above policies. Should I have any questions, I can contact the practice at any time.

PATIENT E‐MAIL AND TEXT MESSAGING

Due to the changing world of healthcare and technology, we now have the ability to provide our patients with certain types of information via e‐mail and/or text messaging.

We believe strongly in protecting the privacy of our patients. When you provide this information to us, it is only used as a way to communicate with you. In order to protect your privacy, no confidential or personal information will be sent from us via email or text messaging. We do not share the names, e‐mail addresses, and/or telephone numbers of patients with any other companies, or with any other patient.

By placing my name and date below, I acknowledge that I have read and understand the above statement on emails and text messages. Should I have any questions, I can contact the practice at any time. I hereby give permission to send messages to me via email and/or text messaging as means of communication.