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New Patient Form

Please complete the following patient information prior to your appointment.

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HIPAA:

Your protected health information is accessed and used for healthcare related purpose only.  Your protected health information is never sold, rented, transferred, exchanged, and/or used for non-health care related purposes including  marketing activities without your written authorization.  Your protected health information is disclosed to third-party entities without your written authorization for purpose of treatment, to obtain payment for  treatment, and for health care operations.  Certain Circumstances: Your protected health information can be disclosed without your written authorization in certain limited circumstances.

For any purpose other than treatment, obtaining payment, healthcare operations, email and text communications or certain circumstances, we will ask for your authorization before using or disclosing your protected health information. If you choose to sign an authorization to disclose protected health information, you can revoke that authorization in writing at any time. With submission of this form, it is considered as your signature to consent to our disclosures of your or responsible parties information that we deem necessary in order to provide proper treatment.

Patients Rights

*Conditions and limitations may apply; obtain additional information at front desk.

Changes of this Notice: We reserve the right to change privacy practices and conditions of this notice at any time and without prior notice. In the event of changes, an update notice will be posted and a copy will be sent to you.