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

My E-mail Address for Reminders/Emails:
Cell Phone Number to Receive Texts: