Acknowledgement of Privacy Practices Acknowledgement of Receipt of Notice of Privacy Practiceshttps://fairmountdenta.wpengine.com/wp-content/uploads/2020/12/Notice-of-Privacy-Practices.pdf * You may refuse to sign this acknowledgement. * I have received a copy of this office's Notice of Privacy Practices.* You can access the privacy policy online using the link above.First Name Last Name Email Address SignaturePrint Name Date MM slash DD slash YYYY CAPTCHA
