I understand the information disclosed in this form may be subject to re-disclosure and may no longer be protected by HIPAA privacy regulations and the HITECH Act.
New Patients: (000) 000-0000
Current Patients: (000) 000-0000
Address:[Address Line 1],[City], [State] [Zip]
Office Hours:Monday | 9am – 6pmTuesday – Friday | 8am – 5pmSaturday & Sunday | Closed