If you have any questions or comments, please don’t hesitate to reach out and we will respond within 24 hours. You can message Remy’s Aloha directly at drpicklo@yahoo.com

Remy’s Aloha Intake Form

By submitting the Intake Form, I hereby authorize use or disclosure of protected health information about me as described below.

  1. The following organization may receive disclosure of protected health information about me:

Remy’s Aloha, operated as Remy Kai, Inc.

www.remysaloha.org

  1. The specific information that should be disclosed is: 

Name, Date of Birth, Address and Phone Number so that contact may be made, and services may be provided by Remy’s Aloha.

  1. I may revoke this authorization by notifying Chris Picklo at Remy’s Aloha in writing of my desire to revoke it.  However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

  2. This authorization expires 1 year from signature date.