Patient Name: ___________________________________________________
Date of Birth: ____________________________________________________
I acknowledge that Larry M. Wolford, DMD – Oral and Maxillofacial Surgery provided me with a written copy of his/her Notice of Privacy Practices.
I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and ask questions.
Patient Signature: ________________________________________________
Personal Representative Signature: __________________________________
Relationship to Patient: ____________________________________________
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