Greg Krenek, M.D., P.A.

503 Medical Center Blvd., Suite 140

Conroe, TX 77304

936-756-0668

Patient Confidentiality Statement

Patients of Greg Krenek, M.D., P.A., have the right of patient confidentiality

on all medical information and laboratory results. All information shall be

held in confidence and shall not be disclosed to any persons, except upon the

expressed consent of the patient or by the guidelines of his/her insurance

company. All biopsy, laboratory results or any other medical information

will only be released to the patient unless otherwise noted below. If the

patient is a minor, all information will be explained to the parents or legal

guardian.

______________________________

______________________________ _________________________ Other person(s) who may receive my Patient name printed

medical information, biopsy and

laboratory results.

______________________________ _________________________ Date Signature

(Parent or legal guardian if patient is

a minor)