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Patient Acknowledgement Form

Privacy

This is a template for Patient Acknowledgement Form. By agreeing to this form, patients acknowledge and understand that he/she will adhere to the Privacy, Payment, and Cancellation Policies of the clinic/hospital.

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01

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02

Fill Information

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03

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04

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Document Description

This is a template for Patient Acknowledgement Form. By agreeing to this form, patients acknowledge and understand that he/she will adhere to the Privacy, Payment, and Cancellation Policies of the clinic/hospital.

The patient agrees:

  • to have received, read and understood the Notice of Privacy Policy, 
  • that all charges are due at the time of service, and that there are no refunds on prepaid treatments
  • to the cancellation policy

How to use this Document?

The patient should read this form carefully.

The form outlines the privacy, payment and cancellation policy of the clinic / hospital. It should be signed by the patient or by the parent/guardian if the patient is a minor.

 

 

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