Privacy Practices Acknowledgement

Dentist in Roseville

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Acknowledgement of Receipt of this Privacy Practices Notice

I acknowledge that I have received and/or reviewed the notice of the Privacy practices of this office. I am aware that I may receive a paper copy of this notice if I request it. In addition, I acknowledge that this notice of the practice's Privacy Practices is posted in the office where I can review it if desired.

Patient or Parent

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