TMJ Therapy
Cosmetic & Restorative Dentistry
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Home > More Information > Acknowledgement of Receipt of Notice of Privacy Practices
Instructions: Please print the following form.  Read carefully, sign at the bottom, and bring with you to your scheduled appointment.
Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgement.
Please Select a Format:

.pdf - Adobe Acrobat - (requires Adobe Acrobat Reader, free download)

.doc - Microsoft Word - (requires Microsoft Word)
Preview:


© 2007 Dr. Peter V. Lecca

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