Acknowledgement of Receipt of Joint Privacy Practices

I have received a copy of the Joint Notice of Privacy Practices of Guzman Orthodontics.

First Name:

Last Name:

Date:

E-Signature of Patient (or Authorized Guardian):

If Guardian, Relationship to Patient:

Witness Name:

Witness E-Signature:

* YOU MAY REFUSE TO SIGN THIS ACKNOWLEDGEMENT *

E-mail and Text Message Approval

I would like to receive e-mails, including appointments reminders, from Guzman Orthodontics. I understand that I can unsubscribe at any time.

I would like to receive appointment reminders via text message. I understand this text message appointment reminder program is completely voluntary and that text messaging fees and rates may apply as determined by my cellular provider. Guzman Orthodontics is not responsible for any fees charged to me by my cellular provider I understand I can unsubscribe at any time.

My E-mail Address for Reminders/Emails:

Cell Phone Number to Receive Texts: