By signing this form, you acknowledge receipt of the Notice of Privacy Practices (the Notice) of Forefront Dermatology, S 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name in the 'Patient Name' field. Ensure that you print clearly for accurate identification.
3. Next, fill in your 'Date of Birth' to confirm your identity and age.
4. Review the communication preferences section. Enter your preferred contact numbers and email address where Forefront Dermatology can reach you.
5. If you consent to receive autodialed calls or messages, ensure to check the appropriate boxes. If you wish to opt-out, mark 'Do Not Text' or 'Do Not Email'.
6. Sign the form at the designated area to acknowledge receipt of the Notice. If someone else is signing on your behalf, indicate their relationship and print their name.
7. Finally, date your signature to complete the acknowledgment process.

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