Tina P. Moses, DMD, PC
You may refuse to sign this acknowledgment.
Click Here to Read our Notice of Privacy Practices
I, the undersigned, have received a copy of this office's Notice of Privacy Practices.
Disclaimer: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
For Office Use Only
Your information will be encrypted.