• Acknowledgement of Receipt of Notice of Privacy Practices

    **You may refuse to sign this notice**
  • I acknowledge that I have received a written copy of this office's Notice of Privacy Practices.

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  • Authorization for Leaving Messages

  • I authorize Drs. Harnois and Kowalczyk's staff to leave a message on my home voice mail, answering machine or other electronic device, mobile phone or with a person who answers my home or mobile phone in regards to my appointment, pre medication, health, or my financial obligations to the practice.

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