Patient Form

Notice of Privacy Practices Acknowledgment (HIPAA)

Please acknowledge that you have been offered access to our Notice of Privacy Practices.

Please do not include emergency medical information in this form. If you are experiencing a life-threatening emergency, call 911.

Select office *

ZIP code

Patient

First name *

Last name *

Acknowledgment

I acknowledge that I have been offered access to Valley Dental Care's Notice of Privacy Practices. *

I understand my information may be used for treatment, payment, and healthcare operations as permitted by law. *

I consent to be contacted regarding appointments and care using the contact information I provided. *

Electronic signature

By typing my name below, I understand and agree that this electronic signature has the same effect as my handwritten signature.

Typed full legal name *

Date

I confirm this is my electronic signature and the information I provided is accurate.

By submitting this form, I understand that Valley Dental Care will use this information to contact me and prepare for my dental visit. See our Privacy Policy and Terms of Use.