Notice of Privacy Consent Form

Please correct the errors described below.

In the event, that you may want a family member or friend to discuss your treatment with our office, we must have consent/permission in writing from you to do so. Please list any person you give Anderson & Hoffner dental Center consent/permission to discuss your information such as account information, x-ray’s, treatment, etc.

In the event, that you may want a family member or friend to discuss your treatment with our office, we must have consent/permission in writing from you to do so. Please list any person you give Anderson & Hoffner dental Center consent/permission to discuss your information such as account information, x-ray’s, treatment, etc.

do not wish for Anderson & Hoffner Dental Center to discuss any of my dental treatment with anyone other than me.

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