Signature Form

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PATIENT SIGNATURE FORM

You must sign and Submit this form to become a patient.

This is a signature page which will be scanned into your chart. By completing these sections and signing below, you acknowledge that you have read and understood all associated forms. We created this form to make it easier for patients to complete the paperwork and to save paper. The forms you are asked to sign are standard and required by law disclosure statements. If you disagree with, or do not clearly understand any of the forms you should not sign at the bottom of this page, and you could not be automatically enrolled as a patient in our practice. In such a case, please call us to discuss your concerns.

STANDARD AUTHORIZATION OF USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Please list the persons to whom information may be disclosed:

You must sign and Submit this form to become a patient.

Person #1

Full Name:

Person #2

Full Name:

Person #3

Full Name:

Please Check ALL:

You must sign and Submit this form to become a patient.
You must sign and Submit this form to become a patient.