Patient Welcome Packet Acknowledgment Form
Please complete this form to acknowledge that you have received and reviewed your welcome packet. This helps us ensure you have all the information you need as a new patient.
Full Name
*
First Name
Last Name
Date of Receipt
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How did you receive your welcome packet?
*
In person
By mail
By email
Patient portal
Other
Which items did your welcome packet include?
*
Practice introduction letter
Office policies
Contact information
Privacy notice
Appointment instructions
Other
Preferred contact method for future communications
Please Select
Phone
Email
Mail
Patient portal
Other
Comments or questions about your welcome packet
I acknowledge that I have received and reviewed my welcome packet.
*
Yes, I acknowledge
Signature
*
Submit Acknowledgment
Submit Acknowledgment
Should be Empty: