Date and Time of Visit

Client Information

• I hereby certify that the information provided in this form is complete, true, and correct to the best of my knowledge. I also acknowledge that I have read and understood the Shalom Medical Clinic Privacy Policy and agree to its terms. I give my consent to Shalom Medical Clinic to collect, use, and process my personal information. I understand that this consent is required for the lawful processing of my personal data and does not waive any of my rights under the Data Privacy Act of 2012 and other applicable laws.