Acknowledgement of Privacy Notice Form

The Acknowledgement of Receipt of Privacy Notice Form (Privacy Practices Form) is required for new patient registration.  It is a government-required form.  To complete this form, please click the link below:


The form above refers to the below notice:

View our Notice of Privacy Practices


If you prefer a downloadable pdf version of this form, please go to the Forms page

827 S Magnolia Blvd Suite 6

Magnolia, TX 77355


Office of:

Paul Dibble MD

Pamela Johnson MD

We will be closed 11/28/2019 (Thu) in observance of Thanksgiving. 


We are open our other hours as usual, including 11/29 (Fri) and 11/30 (Sat)

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