Welcome to our practice. In an effort to provide the best service possible, we ask you to fill out this form as completely as possible. Thank you for your cooperation. All information is encrypted and transmitted using a secure connection.
If you have dual coverage, please complete.
Acknowledgement of receipt of Notice of Privacy Practice Consent for use and disclosure of health information.
I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child’s medical status.