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  • Disclaimer

    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 the patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

  • Disclaimer

    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 the patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

  • Notice of Privacy Policies
    Acknowledgement of Receipt of Notice of Privacy Practices

  • A copy of our Additional Disclosure Authority Section was made available and I acknowledge receipt of that notice.

  • Electronic Data

    Do we have your permission to transmit your information by conventional email to other offices for referrals or communication? There may be some level of risk that the information in these emails could be read by a third party. We currently use a HIPAA compliant encrypted email service.

    I have had the full opportunity to read and consider the contents of the Notice of Privacy Practices. I understand that I am giving my permission to Green Mountain Endodontics for use and disclosure of my protected health information in order to carry out treatment, payment activities, and healthcare operations. I also understand that I have the right to revoke permission.

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