Page 8 - Forms - New Patient Paperwork (Dec-2017)_Neat
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HEALTH INFORMATION PRIVACY AGREEMENT
Part 2 of 2
The patient acknowledges that his/her breach of this Agreement may result in serious, irreparable harm.
In the event of a breach of any of the terms of this Agreement by the patient, the practice shall be entitled
to recover from the patient all remedies or damages available at law, as well as equitable relief (including
but not limited to injunctive relief) and all costs and expenses, including reasonable attorneys’ fees
incurred by enforcing any rights hereunder.
The patient has carefully read the Agreement, has been given the opportunity to ask questions about the
Agreement’s meaning and understands and accepts the terms.
_________________________________________________ _________________
Patient or Parent/Guardian Signature Date
Relationship: (circle one) PATIENT PARENT GUARDIAN
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