Notice Of Privacy Practices

This document is posted in lobby and copies are available at request

“You may refuse to sign this acknowledgement”
I have received/been advised of this offices “Notice of Privacy Practices.”

I agree that the dental practice may communicate with me electronically at the email address and/or cell phone number below

I am aware that there is some level of risk that third parties might be able to read unencrypted emails and/or text messages.
I am responsible for providing the dental practice any updates to my email address and cell phone number.
I can withdraw my consent to electronic communications by calling: 586-293-8750.

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained