WILLIAM BLANE RICHARDSON, MD

| SOUTHERN GRACE PRECISION & AESTHETICS

WILLIAM BLANE RICHARDSON,MD

SOUTHERN GRACE PRECISION & AESTHETICS

Patients Confidentiality Form

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Patient Address


The current medical community has worked hard to ensure patient confidentiality and protect each patient’s rights to privacy within today’s high-speed information society. The government has developed laws and guidelines to maintain patient physician privacy and this includes discussing patient diagnoses, medications and treatment modalities with anyone other than the patient themselves without the direct and documented consent of the patient.
Please complete the following information, allowing that person, and only that person to be allowed access to your medical information.
You are not required to grant anyone access to discuss your medical care at Southern Grace Pain & Regenerative Medicine, however, if you would like someone else access you may do so by completing the below information.
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