Please complete this form to speed up the processing of your information when you arrive at our office.
After you complete the pertinent information print a copy to your printer, sign, and take with you at the time of exam.

Patient Request
Information my be released to the following individuals/organizations for the indicted purpose.
Individual/Organization Purpose

Patient Request For Restrictions
Please check all of the apllicable actions
I request the following restrictions to the use and/or disclosure of my health information.

PROHIBIT SPECIFIC RECEIVERS: I request that you disclose ANY of my protected health information to the specific persons/organizations listed here:

OTHER REQUEST: I request that you restrict the user or disclosure of my protected healther information in the specific manner described below:

Your permission is needed to leave appointment reminders / medical information on your message service or machine. We do not use email as a means of contact for safety reasons.

Termination of Restrictions
I request to terminate the restrictions that are listed above.
I request to revise the restrictions that are listed above. The are as follows:

Patient Name
Patient Birthdate
Patient Social Security
Signature of Patient or Legal Representative