NOTICE AND ACKNOWLEDGMENT
OF RECEIPT AND UNDERSTANDING
NOTICE TO PATIENTS
Medical doctors are licensed and regulated by the Medical Board of California.
To check up on a license or to file a complaint go to
www.mbc.ca.gov,
email: licensecheck@mbc.ca.gov,
or call (800) 633-2322.
__________________________
Date
Date
__________________________________
Patient’s Name (Type or Print)
Patient’s Name (Type or Print)
__________________________________
Patient’s Name (Type or Print)
Patient’s Name (Type or Print)
__________________________
Date
Date
__________________________________
Patient Representative’s Name
and Relationship (Type or Print)
Patient Representative’s Name
and Relationship (Type or Print)
__________________________________
Patient’s Representative’s
Signature
Patient’s Representative’s
Signature
