Parent/Adult Vaccine Registration

I acknowledge that the Physician's Notice of Privacy Practices has been offered to me. The Notice of Privacy Practices provides detailed information about how the practice may use and disclose my confidential information. I understand that the physician has reserved the right to change his or her privacy practices that are described in the Notice. I also understand that a copy of any Revised Notice will be provided to me or made available to me.

I acknowledge that I am aware of East Portland Pediatric Clinic's financial policy and will be given a copy upon request

I hereby authorize the physicians and providers of East Portland Pediatric Clinic, P.C. to provide such medical services, regular or emergency, as may be determined to be in my best interest. This authorization shall continue and be in full force and effect until revoked in writing by me.