Allergy and Asthma Clinic - Suzanne Weakley, MD

Acknowledgement of Review of Notice of Privacy Practices I have reviewed (or been offered the opportunity to review) this office’s Notice of Privacy Practices, which explains how Suzanne Weakley, MD will use and disclose my medical information. I understand that I am entitled to receive a copy of this document. I authorize the office of Dr. Suzanne Weakley to leave messages regarding appointments and/or lab results at the following locations:
Home telephone or family member:	Yes No Not Applicable
Home Answering machine:	Yes No Not Applicable
Work Phone or Voicemail:	Yes No Not Applicable
Cell Phone:	Yes No Not Applicable
Email Address:
Other Phone/email/contact: (please provide information below)
Other Instructions:
Name of Patient OR Personal Representative:
Relationship to patient:
Date:	/ /