RICHARD A. QUALLS, JR., D.C.

PATIENT PRIVACY. Our practice is committed to securing the privacy of your health information.  Accordingly, we have given you a copy of Dr. Qualls' Notice of Privacy Practice; you are not required to read this notice.  However, we would like your acknowledgement that you were given a copy of this notice. 

Signature__________________________________ Date____________________

You may contact me for appointment reminders and office matters at:
(Check all that apply)

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You may disclose my health information to:

No one other than myself
My spouse (name)
Other (name)