Westboro Harassment Policy Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment. VI. Acknowledgment of Receipt of PolicyI acknowledge receipt of this PROTECTED CLASS HARASSMENT PREVENTION POLICY from Suzanne Lucash O.D. PLLC, and I have read its contents.Name* First Last Signature*Date* NameThis field is for validation purposes and should be left unchanged.