HIPAA ACKNOWLEDGMENT
Patient First Name
Patient Last Name
Birth Date
Click on the hyperlink to obtain a copy:
Generations Dental Care Notice of Privacy Practices
I have reviewed the Notice of Privacy Practices for Generations Dental Care and agree to the terms as required by NH State law
I give Generations Dental Care permission to discuss my dental treatment, billing, and appointments by phone, fax, mail, and/or email with:
Printed Name of Authorized Person
Relationship to Patient
Email
Telephone
Printed Name of Authorized Person
Relationship to Patient
Email
Telephone
Signature of Patient, Parent or Guardian
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Clear
Please sign the document
Date
If Patient Is A Minor
Form signed by
Relationship to Patient
Online Signature
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Draw your signature inside the box
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