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  • ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY POLICY

     You may refuse to sign this acknowledgement*

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  • Signature:    _____________________________________

    (The signature above will be physically signed when at the dental office.)

  • For Office Use Only


  • © 2002 American Dental Association

    All Rights Reserved

    Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other parties requires the prior written approval of the American Dental Association.

    This form is for education only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).

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