I acknowledge and agree that I have been provided a copy of the Notice of Privacy Practices for Vivo MedSpa and Wellness Institute that describes how my protected health information must be protected and my rights to access and control such information. I acknowledge and agree that I have reviewed the Notice of Privacy Practices in its entirety and have been given the opportunity to ask any questions regarding the use or disclosure of my protected health information and my associated rights. I acknowledge and agree hat I have had all my questions answered to my satisfaction. *

PATIENT SIGNATURE (OR PERSONAL REPRESENTATIVE)

Date *

PRINTED NAME *

PERSONAL REPRESENTATIVE’S AUTHORITY (IF APPLICABLE) *

FOR OFFICE USE ONLY *

We will make a good faith effort to obtain a written acknowledgment of receipt of the notice of privacy practices provided to each patient. If a patient is unwilling or unable to sign this acknowledgement, the good faith efforts to obtain such acknowledgment and reason why the acknowledgment was not obtained must be documented.

Staff Signature *