Acknowledgement of Receipt of Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

Patient Information

First Name *

Last Name *

Middle Initial

We use a confidential service called RevenueWell to make contact with our patients about appointments and office information. When confirming appointments we can send you an email, text or give you a courtesy phone call.
Please choose the way(s) you would like to be contacted by our office about your appointments.

How Would you like to be contacted by out office? *

Emergency Contact: *

Phone Number: *

Was there a reason you left your last dental practice?

Please indicate below any person or persons you give us permission to discuss your information with. (Example: Spouse, Son, Daughter, etc.) Please list any information you wish to exclude from this privacy permission. (Example: Account, Appointments, Medical Information, etc.)

Name

Home Phone

Cell Phone

Relationship

Information Excluded

Name

Home Phone

Cell Phone

Relationship

Information Excluded


​​​​​​​Sign Form *

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Relationship to patient

Name