By signing this form, you are granting consent to ZYGO Industries, Inc. to use and disclose your protected health information for the purposes of treatment, payment and health care operations. By signing this form you are acknowledging that ZYGO Industries, Inc. has provided you with a copy of Our Notice of Privacy Practices which provides detailed information about how we may use and disclose this protected health information.

Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by accessing our web site at www.zygo-usa.com/privacy.htm and/or contacting us at 1-800-234-6006.

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