Notice of Privacy Policies
READ ONLY – Please read/review prior to signing the Client Information Form. Print and keep for your records.
Client Rights and Responsibilities
READ ONLY – Please read/review prior to signing the Client Information Form. Print and keep for your records..
For Adults (18 yrs. & older) with a scheduled appointment, complete the TOP section titled “PATIENTS 18 OR OLDER ONLY” and sign the back (Highlighted in BLUE)
For Children with a scheduled appointment, Parents OR Foster Parents must complete the section titled “PARENT OR FOSTER FAMILY INFORMATION” and “CHILDREN INFORMATION” section. Sign the back as either (Legal Guardian/Parent – Highlighted in BLUE) or for Foster Parent (Highlighted in YELLOW)
NOTE: All Patients must complete the Payment Responsibility Section with correct insurance provider information or specify as CASH PAY. All cash pay patients will need to keep a valid credit card on file for payments.