As a new patient, I hereby consent to and acknowledge receipt of Speechcenter’s Notice of Privacy Practices or as a current patient, I consent to and acknowledge the availability of Speechcenter’s Notice of Privacy Practices. I understand the notice explains my rights to privacy regarding my health information and provides information and a description of how my health information may be used and disclosed. My requests are recorded below.

I agree that Speechcenter, Inc. may communicate with me electronically at the phone numbers and/or email addresses I have provided or used to contact its staff, unless I have requested a more confidential means of communication in writing. By accepting electronic communications, I understand these cannot be guaranteed as secure forms of communication.

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