Email Security Acknowledgement

  • E-MAIL Security Policy

    Acknowledgement & Response

    BOTH this AND the separate Acknowledgement of Notice of Privacy Practices
    forms MUST be completed, either here online or on paper, before we can
    communicate with you by email.

    Name and email of parent/guardian/18yr+ patient completing form:

  • This can be found on any office statement or receipt, or on any previous school form. Enter only digits to the left of decimal (ignore the decimal point and digits after the decimal point i.e. 1234.1, 1234.2, and 1234.3 together need only one form with number entered as 1234).

  • One patient per form, please.
  • Check the appropriate box below:
    Your choice can be changed/revoked at any time in the future by submitting a new copy of this form.