Notice of Privacy Practices Acknowledgement of Receipt

I acknowledge that I was provided a copy of the “Notice of Privacy Practices” and that I have read (or have had the opportunity to read, if I so choose) and understand the notice.

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I authorized The Foot and Ankle Center of Kirkland to leave detail voicemail message regarding my appointment AND my care and/or my treatment information at the phone number I have provided.

I DO NOT authorize The Foot and Ankle Center of Kirkland to leave detail voicemail message regarding appointments, care and/or treatment information at the phone number I have provided.

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All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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