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.”

Name

Signature

Date

I authorize Dental Care of the Future to share information with: My Spouse My Family Other

Other (Please List)

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.

Email Address

Cell Phone Number (For Text Messages)

Signature

Date

For Office Use Only

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

Office Use Only Individual refused to sign Communication barriers prohibited obtaining acknowledgement An Emergency situation prevented us from obtaining acknowledgement Other (please specify)