ACCOUNT_ADDRESS_SINGLE_LINE
ACCOUNT_PHONE_NOACCOUNT_EMAIL
ロ I acknowledge that I have received, read and understood the Notice of Privacy Policy of ACCOUNT_JOB_COMPANY. The Notice describes how my medical information received by ACCOUNT_JOB_COMPANY may be used or disclosed by the ACCOUNT_JOB_COMPANY and my right to access this information.
ロ I understand and agree that ACCOUNT_JOB_COMPANY may use and disclose my personal health information to help provide healthcare, to handle billing, insurance and payment, and to take care of other health care operations. I also authorise ACCOUNT_JOB_COMPANY to send electronic communication which may contain protected health information to either my e-mail account or personal health record.
ロI understand that all charges are due at the time of service, and that there are no refunds on consultations and/or treatments. I agree to pay ACCOUNT_JOB_COMPANY for all charges for the treatment and/or consultation provided to me, or my dependent.
ロ I acknowledge that I have read and understood the cancellation policy of ACCOUNT_JOB_COMPANY i.e.
CANCELLATION_POLICY
By signing below, I acknowledge that I understand and will adhere to the Privacy, Payment, and Cancellation Policies of ACCOUNT_JOB_COMPANY
Patient Name:
Patient Signature:
Date:
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