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Patient Forms - Notice of Privacy Practices  

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Click on the link below to review the Notice of Privacy Practices.

Notice of Privacy Practices Form (pdf)

After reading the Notice of Privacy Practices, you may digitally sign the form by entering your name and date below. Otherwise, you may sign the form when you arrive for your appointment.

Patient name:

By typing your name in the space provided below, this serves as your digital signature which affirms you have received a copy of the Lenz Family Dental's notice of Privacy Practices and agree to its terms.

Signature (Please type your full name): Signature is Required.

     Date: 

Relationship to Patient (if signing for patient)



I give you permission to discuss my account and/or treatment with:




 
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