Notice of Privacy Practices

    I hereby acknowledge that I received a copy of this medical practice’s Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that a copy of any amended Notice of Privacy Practices will be available at each appointment.

    If not signed by the patient, please indicate relationship:

    Consent for Medical Treatment

    I,
    give permission to

    for treatment including medications and others medical procedures, I understand that I’ll be treated by the medical director and/or physicians assistants.

    Patient’s Signature


    (If the patient is minor, signs the parent or tutor)

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