Our Notice of Privacy Practice is posted for our patients in our reception area. You have the right to request a copy of this office’s Notice of Privacy Practices at anytime. It can also be found on our website at

By signing this form, you are aware of this office’s Notice of Privacy Practices and consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and dental/healthcare operations.

Click on the hyperlink to obtain a copy:

*You May Refuse to Sign This Acknowledgment*

Please list authorized persons with whom we may discuss your Protected Health Information (PHI) in addition to custodial parents and legal guardians:

Form Completion

If Patient Is A Minor

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