New Patient Registration

Acknowledgement & Agreement

I certify that all information submitted in this form is correct and may be used by Doctor Clinic to provide services to me. I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for electronic communications, it is possible that communications with the Physician or the Physician’s staff using the Services may not be encrypted. Despite this, I agree to communicate with the Physician or the Physician’s staff using these Services with a full understanding of the risk. I acknowledge that either I or the Physician may, at any time, withdraw the option of communicating electronically through the Services upon providing written notice.

​

Are you completing this form on behalf of a child under the age of 16 years? *

​

 Yes  No

​

Patient Details

​