Patient Acknowledgment - Dr. Boris A. Khaimov, D.O.

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Patient Identification

Used to file this form with the correct patient record. (Not part of the original paper form.)

Patient First Name*

Patient Last Name*

Date of Birth*

Patient Acknowledgment

I hereby acknowledge that I have received a copy of the Notice of Privacy Practices of Boris A. Khaimov, DO, Child, Adolescent and Adult Psychiatrist.

Signature of Patient (or authorized representative)*

First Name*

Last Name*

Signature preview

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Name of Patient (please print)*

Date*

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