Patient Information

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Person Responsible for Account (if other than Patient)




ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
** You may refuse to Sign this Acknowledgement**

I, the undersigned, certify that I have read, understand, and agree to abide by the above policies.

I have received a copy or have been given access to the Smiles of Johns Creek Notice of Privacy Practices. I give my permission to Smiles of Johns Creek to:

  • Communicate with other health care professionals and dental insurance carriers (if applicable) as needed throughout the course of my care.
  • Leave messages for me at my contact numbers provided and mail or email reminders to me regarding appointment dates and times.

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