PATIENT’S REGISTRATION FORM
EMERGENCY CONTACT INFORMATION
PLEASE COMPLETE IF PATIENT IS LESS THAN 18 YEARS OF AGE: *
In our efforts to comply with the Health Insurance Portability and Accountability Act (HIPPA), we need to be certain that we guard your privacy according to your wishes when it come to your family , friends, and co-workers.
Please check your response to the following:
By signing this registration form, I acknowledge receipt of the Absolute Health Family and Urgent Care Clinic, Privacy of Notice. I understand my rights to privacy and know if I have any questions or specific requests that I may direct them to Office Manager.