SIGNATURE OF PATIENT: I understand the need for these questions to be answered truthfully. To the best of my knowledge, the answers I have given are accurate. I also understand it is very important to report any changes in my medical or dental status to the dentist at the earliest possible time, and I agree to do so. I give permission to the dentist to obtain from my physician any additional information regarding my medical history needed to provide me with the best dental treatment possible.
ACKNOWLEDGEMENT OF RECIEPT OF HIPPA PRIVACY PRACTICES
NOTE: You may refuse to sign this acknowledgement.
I have reviewed a copy of this office’s HIPPA Notice of Privacy Practices.
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