Patient Acknowledgement of the Notice of Privacy Practices of Dr. Jennifer Shaba Yalldo O.D. and consent for use and disclosure of personal health information.

By signing below, I hereby acknowledge that I have either received a copy of this office's Notice of Privacy Practices or that this office's Notice of Privacy Practices was made available for me to receive and the consent to the use of my personal health information by your office as outlined in the Notice of Privacy Practices.