Patient Acknowledgement of Receipt of Notice of Privacy Practices | Larry M. Wolford, DMD

Patient Acknowledgement of Receipt of Notice of Privacy Practices

Please Print Patient Acknowledgement of Receipt of Notice of Privacy Practices Using The Button

Larry M. Wolford, Dmd | Oral &Amp; Maxillofacial Surgery | Jaw Surgeon Logo

DR. LARRY M. WOLFORD – ORAL AND MAXILLOFACIAL SURGERY CLINIC

Patient Name: ___________________________________________________

Date of Birth: ____________________________________________________

I acknowledge that Larry M. Wolford, DMD – Oral and Maxillofacial Surgery provided me with a written copy of his/her Notice of Privacy Practices.

I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and ask questions.

Patient Signature: ________________________________________________

Date: ______________________________

Personal Representative Signature: __________________________________

Relationship to Patient: ____________________________________________

 

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