Practice Consent Notice of Privacy Practices Acknowledgement Full Name * By signing this form below, you acknowledge receipt of the Notice of Privacy Practices from Saint Louis Immigration Exams. The Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it carefully. The notice of privacy practices is subject to change. If the Notice is changed, you may obtain a revised copy by visiting our website at www.immigrationexams.com or upon request from our staff. I acknowledge receipt of the notice of privacy practices from Saint Louis Immigration Exams. email * Date of Birth * Person authorized to receive information Relationship to Patient Parent Spouse Child Friend AttorneyYour privacy is important to us, and we want to protect it as much as possible. By signing this form, you authorize St Louis Immigration Exams to disclose information as is pertains to your immigration exam and vaccinations to the individual(s) you list below. Person(s) Authorized to Receive Information Opt-In Text Messaging Yes NoSt Louis Immigration Exams complies with HIPAA and wants to exchange text messages with you . Text messaging may not be entirely secure. To consent simply sign below. Submit
