Go Paperless Statements

Go Paperless Statements Acknowledgment Form

Pattison Professional Counseling and Mediation Center (PPCC Inc) is offering a paperless statement option and, therefore, we will be providing patient statements via email.
Please provide the following information:
Legal Name*

First NameMiddle NameLast NameSuffix
Last 4 digits of your social*
Date of Birth*

MonthDayYear
Enter your date of birth
Name of Counselor (optional)
Enter the name of the counselor you will be seeing
In addition to receiving paperless statements, you will be receiving a monthly newsletter providing you with interesting articles and informative information pertaining to health and wellness. You may opt-out of receiving the newsletter at any time.
I hereby acknowledge that I will be receiving statements via email:*

Sign full name using finger, mouse, trackpad, or digital pen. Clear
Date*

MonthDayYear
Date
Should be Empty:

Go Paperless Statements Acknowledgment Form