www.smileoasis.com - Acknowledgement of Receipt of Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

*You may refuse to sign this acknowledgement*
Patient Name

First NameMiddle NameLast Name
I {patientName} have received a copy of this office’s Notice of Privacy Practices.
Signature
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: