I have been given the opportunity to review the notice of Privacy Practices for Chester Oral Surgery (COS). I understand the terms stated herin are to remain in effect throughout my treatment with COS.

The following people are authorized to speak on behalf of my account and/or treatment plan:

Name

Relation to Patient

Phone #

Account

Treatment Plan

Name

Relation to Patient

Phone #

Account

Treatment Plan

Name

Relation to Patient

Phone #

Account

Treatment Plan

Messages with confidential information may be left at:

Home

If you've selected home, please specify a home phone #

Work

If you've selected work, please specify a work phone #

Other

If you've selected other, please specify a other phone #

Cell Phone

If you've selected cell, please specify a cell phone #

E-mail

If you've selected email, please specify an email

Appointment Confirmation Preferences

Phone Call

Text Message

Health History Form

Please answer all question to the best of your ability and check off the condition(s) that apply.

I agree the answers given above are honest and accurate as possible.

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.

Thank You!

Acknowledgement of Receipt of Privacy Practices

Appointment Confirmation Preferences

Thank You!

Thank You!