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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Patient Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
I have received a copy of this office's notice of privacy practices
*
Yes
No
Date
*
-
Month
-
Day
Year
Date
Patient Signature
*
Clear
Parent Signature
*
Clear
Submit
Should be Empty: