PROFILE AGREEMENTProfile Agreement • September 26th, 2021 • New York
This Profile Agreement (“Agreement”) is made as of Date Signed Up (the “Effective Date”), by and between Furry Best Friend, Inc. (“Company”) and [Veterinary
Account Profile AgreementProfile Agreement • October 12th, 2018
Name of Subscriber Name of End User (If different fromSubscriber) First Name: First Name: Last Name: Last Name: Email: Email: Address: Address: City: City: State: State: Zip: Zip: Phone: Phone: Designated caregivers to be notified for assistance. Name of Caregiver 1: Phone: Name of Caregiver 2: Phone: Name of Caregiver 3: Phone: Notice of Medication Call Reminder Practices and Privacy Statement Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. By signing this form, you consent to our use and disclosure of protected health information about you for to facilitate your medication reminder service. You have the right to revoke this Consent, in writing, signed by you. The Service provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Medication Call Reminder has implemented policies, processes, and procedures designed to ensure compliance with Federal and State in
