Patient Medical History Form Page 2
ADVERTISEMENT
1
2Record of Privacy Practice Notifications
I certify that I have been offered a copy of the office’s Notice of Privacy Practices at my visit today:
Patient/ Legal Guardian Signature: __________________________________________________________
Date: ______________
Only one signature per visit is required.
I certify that I have been offered a copy of the office’s Notice of Privacy Practices at my visit today:
Patient/ Legal Guardian Signature: __________________________________________________________
Date: ______________
Only one signature per visit is required.
I certify that I have been offered a copy of the office’s Notice of Privacy Practices at my visit today:
Patient/ Legal Guardian Signature: __________________________________________________________
Date: ______________
Only one signature per visit is required.
I certify that I have been offered a copy of the office’s Notice of Privacy Practices at my visit today:
Patient/ Legal Guardian Signature: __________________________________________________________
Date: ______________
Only one signature per visit is required.
I certify that I have been offered a copy of the office’s Notice of Privacy Practices at my visit today:
Patient/ Legal Guardian Signature: __________________________________________________________
Date: ______________
Only one signature per visit is required.
Page 2 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical