As required by the Health Information Portability and Accountability Act of 1996 (HIPAA) and state law, this practice may not use or disclose your individually identifiable health information except as provided in our Notice of Privacy Practices without your authorization. Your completion of this form means that you are giving permission for the uses and disclosure described below for the express purpose of internal admissions and external marketing, including: email correspondence, phone calls, internal mailing lists, SMS messaging, post, and Customer Relationship Management (CRM) entry and mailing tools for internal information management and communications management. In addition, after care processes such as follow-up correspondence post treatment via email, phone, or post, may be initiated using your personally identifiable information submitted in this form. Mindful Rejuvenation Inc. will not share your private information with third parties not directly involved in the facilitation and execution of the internal uses outlined above. Mindful Rejuvenation Inc. will never sell or share your information to third parties for the purposes of marketing or market research. By clicking “I agree to share my information with Mindful Rejuvenation Inc” you signify that you have read and understand this explicit & informed consent for use of your personally identifiable information by Mindful Rejuvenation Inc.