![]() If a teacher, in connection with his employment, is subjected to assault or battery, he shall immediately report the incident and the circumstances to his Principal. This cooperation may include the exchange of information on legislative work and institutional reform, the establishment of permanent systems of mutual information on dangerous products, the improvement of information provided to consumers, especially on prices, characteristics of products and services offered, the development of exchanges between consumer interest representatives, and increasing the compatibility of consumer protection policies, and the organisation of seminars and training periods. ![]() Related to Telephone Consumer Protection Act (TCPAĬonsumer Protection The Parties shall enter into close cooperation aimed at achieving compatibility between their systems of consumer protection. ![]() FAMILY PHYSICIAN PH # ( ) PHARMACY NAME/CITY PH # ( ) REFERRING PHYSICIAN NAME PHONE NUMBER ( ) WHO IS THE INSURED PATIENT SPOUSE MOTHER FATHER OTHER FOR STUDENTS AND/OR MINORS ( UNDER 18) THIS SECTION MUST BE COMPLETED IN FULL IF THIS VISIT IS WORK, AUTO, OR LIABILITY RELATED, PLEASE ADVISE OUR FRONT DESK SO THEY MAY PROVIDE YOU WITH ADDITIONAL REQUIRED PAPERWORK. AGE SEX MARITAL M/F/other S-M-W-D PREFERRED NAME: STREET ADDRESS CITY STATE ZIP SS# HOME PHONE ( ) CELL PHONE ( ) E-MAIL NAME OF EMPLOYER EMPLOYER PHONE NUMBER ( ) EMPLOYER ADDRESS SPOUSE’S NAME SPOUSE'S ADDRESS (IF DIFFERENT) SPOUSE'S PHONE ( ) D.O.B. Signature of Patient (parent/guardian) Printed name of Patient (parent/guardian) Date WESTFIELD ORTHOPEDIC GROUP PLEASE PRINT LEGIBLY AND COMPLETE ALL INFORMATION WESTFIELD ORTHOPEDIC GROUP PLEASE PRINT LEGIBLY AND COMPLETE ALL INFORMATION LAST NAME FIRST MI D.O.B. Signature of Patient ( parent/ guardian) Printed name of Patient (parent/guardian) Date By signing this form I agree to all of the above policies. I/We have read this disclosure and agree that Westfield Orthopedic Group, its employees and/or agents may contact me/us as described above. Methods of contact may include using prerecorded/ artificial voice messages and/or use of automatic dialing device, as applicable. We may also contact you by sending text messages or emails, using any email address you provide to use. You agree, in order for us to service your account or to collect monies you may owe, Westfield Orthopedic Group and/or our agents may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you.
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |