• Acknowledgement Form - Couple


    We acknowledge that we have read and understand the information included in Dr. Korngold’s Office Policies and Informed Consent. We agree to abide by these office policies during our professional relationship. We also acknowledge that we have read and understand the information included in Dr. Korngold’s Notice of Privacy Practices. We have had the opportunity to discuss any concerns with Dr. Korngold and we consent to treatment.

  • Date Format: MM slash DD slash YYYY

  • Date Format: MM slash DD slash YYYY

A copy of this form will be emailed to both of you as well.

If you would rather print out, sign and bring this form to your first appointment, please download document here: Acknowledgement Form – Couple (PDF)