Warr PDA Acknowledgement of Receipt
of Notice of Privacy Practices

All information in this form is confidential and transmitted over a secure, encrypted connection.
(*) indicates a required field.

Patient Name *

Patient Address *

Street Address *

Apt #

City *

State *

Zip Code *

I have received a copy of the Notice of Privacy Practices for the above named practice.

Signature of Parent or Legal Guardian *
(Please use your mouse or finger on a touchscreen to sign in the box.)

Date *