Notice of Privacy Practice

Please Fill out our

Notice of Privacy Practice Form

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Patient Name

Birth Date

Free Text

I have been given a copy of Southampton Aesthetic Dentistry. Notice of Privacy Practices (”Notice”), which describes how my health information is used and shared. I understand that the Practice has the right to change this notice at any time. I may obtain a copy by contacting the Practice Privacy Offier.

My signature below acknowledges that I have been provided with a copy of the Notice of Privacy Practices:

Signature of Patient or Personal Representative

Date

Print Name

Personal Representative’s Title, if applicable

Free Text

For Facility Use Only: Complete this section if you are unable to obtain a signature If the patient or personal representative is unable or unwilling to sign this Acknowledgment, or the Acknowledgment is not signed for any other reason, state the reason:

Signature of Patient or Personal Representative

Date

Print Name

Office location

Phone Number

Email Address

Office Location

Phone Number

Please Fill out our

Notice of Privacy Practice Form

Contact Us