• PATIENT INFORMATION

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  • DENTAL HISTORY


  • HIPAA Notice of Privacy Practice

    Notice to Patient: We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge reciept of this notice. You may refuse to sign this acknowledgement, if you wish.

    I acknowledge that I have received a copy of this office's Notice of Privacy Practices and have read the contents. I understand that I am giving my consent to use and disclose my health care information to carry out treatment, education, payment activities and health care options

     

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  • Medical Information Release

  • Release of Information
    I authorize the release of information including the diagnosis, records; examination rendered to me

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