Exhibit 4

EAST PORTLAND NEUROLOGY

Receipt of Notice of Privacy Practices Written Acknowledgement Form

I, _______________________________, have received a copy of East Portland Neurology's Notice of Privacy Practices.

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Signature of Patient

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Date

Please print this form, fill in the entries, sign, and return to the office of East Portland Neurology:

East Portland Neurology
10101 S.E. Main Street, Suite 1006
Portland, Oregon 97216