[contact-form-7 404 "Not Found"]
[contact-form-7 404 "Not Found"]
[contact-form-7 404 "Not Found"]

    Acknowledgement of Receipt of Notice of Privacy Practices

    Our Notice of Privacy Practices provides information about how we may use and disclose protected health information ("PHI") about you. You have the right to review our notice and ask questions about our privacy practices. as provided in our Notice, the terms of our Notice may change. If we change our Notice, you will receive a revised copy at the time for first service after the change.

    You have the right to request that we restrict how PHI about you is used or disclosed for treatment, payment or healthcare operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement.

    By signing this form you acknowledge that you have received our 'Notice of Privacy Practices'.

    To access your PATIENT PORTAL Please provide us with your email address:

    A temporary password will be assigned upon checking out.