Click "Create Document" button and the document will be prepared with your account details automatically filled in.
Please fill in any additional information by following the step-by-step guide on the left hand side of the preview document and click the "Next" button.
When you are done, click the "Get Document" button and you can download the document in Word or PDF format.
Please review the document carefully and make any final modifications to ensure that the details are correct before publication / distribution.
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:
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.