**You may refuse to sign this acknowledgment** 

I acknowledge that the orthodontic practice (Central Virginia Orthodontics) provided me with the Notice of Privacy Practices.

 Patient's Date of Birth:
 

Patient or Parent/Legal Guardian Signature:

Relationship to patient (If parent or Legal Guardian)

Date:
 

 

Please list below anyone you wish to allow access to your medical information. If none, please put a check below.
 None

Name of 1st Person:
Relationship of 1st Person:
Phone Number of 1st Person:

Name of 2nd Person:
Relationship of 2nd Person:
Phone Number of 2nd Person:

Name of 3rd Person:
Relationship of 3rd Person:
Phone Number of 3rd Person:

Name of 4th Person:
Relationship of 4th Person:
Phone Number of 4th Person:

You may add to or delete from this list at any time. Please notify us in writing of any changes.