Westboro Sexual 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 SEXUAL HARASSMENT PREVENTION POLICY from Suzanne Lucash O.D. PLLC and I have read its contents.Name* First Last Signature*Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.