Central VA HIPPA Form
7802 Timberlake Rd. Lynchburg, VA 24502
(434) 385 - 4746
**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 or Parent/Legal Guardian Signature:
You may add to or delete from this list at any time. Please notify us in writing of any changes.