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Receipt Of Privacy Notice

PATIENT ACKNOWLEDGEMENT OF

RECEIPT OF NOTICE

I hereby acknowledge receipt of the Notice of Privacy Practices for Taylor Chiropractic regarding my health information. I have been informed and understand the manner in which my health information shall be maintained, utilized and disclosed by Clinic and my respective rights contained there in. I also understand that the Notice furnished to me is subject to change at any time. I am aware that I may obtain a current copy of this Notice at any time by contacting Darrin M. Taylor, DC at 1185 Westwood Drive, Van Wert, Ohio 45891. My signature herein below constitutes full acknowledgement that I have furnished a copy of the Notice of Privacy Practices for Taylor Chiropractic.



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Patient Signature Date

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Patient’s Legal Representative Date

if required

If signed by patient’s legal representative, please state representative’s relationship to patient:


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Hours of Operation

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Ours of Operation

Monday:

9:00 am-6:00 pm

Tuesday:

2:00 pm-6:00 pm

Wednesday:

9:00 am-6:00 pm

Thursday:

9:00 am-6:00 pm

Friday:

9:00 am-1:00 pm

Saturday:

By Appointment

Sunday:

Closed

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