Acknowledgement of Privacy Practices Acknowledgement of Receipt of Notice of Privacy Practiceshttps://fairmountdental.me/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 Signature Reset signature Signature locked. Reset to sign again Print Name Date MM slash DD slash YYYY CAPTCHA
