Agreement

Agreement Form

Prior to your first appointment it is important that you have reviewed the practice policy and privacy document found under “policies.” In addition, completion of the patient information form is necessary to confirm the initial appointment. Please print a copy of this form for your record. If you have any questions, please contact Dr. Barowsky prior to completing the documentation.
 

Name
Email

I acknowledge receipt and review of Dr. Barowsky’s practice policies.
I acknowledge receipt and review of Dr. Barowsky’s policy regarding credit card authorization.
I acknowledge receipt and review of Dr. Barowsky’s privacy practices.
By checking the above boxes I agree to the indicated provisions as if signing my name.