HIPAA Privacy Info

Child's Name*
Parent/Guardian Name*
Phone*
Email*
May we leave appointment messages…
(Please initial next to the items that you wish to authorize)
On an answering machine?
On office voicemail?
With another person?
Sent through the mail?
Sent via email?
May we leave other medical information…
(Please initial next to the items that you wish to authorize)
On an answering machine?
On office voicemail?
With another person?
Sent through the mail?
Sent via email?
Please list any other person(s) other than yourself who are authorized to discuss any of the above:
Name
This field is for validation purposes and should be left unchanged.

May we leave appointment messages…