Please keep the MIDTOWN DENTAL'S Financial Policy and the Notice of 
Privacy Practices for your records and return this signature page to front office.

By signing below you acknowledge the Midtown Dental's Office and Financial Policy
and the Notice of Privacy Practices.
Patient or Responsible Party Signature:

X___________________________________________Date______________________ 
CONTACT RELEASE INFORMATION: I agree to permit MIDTOWN DENTAL and 
their business associates to contact me, and all other responsible parties on my account,
on our cell phone or other mobile devices concerning any and all aspects of my account.
X__________________________________________ Date_______________________

______________________________________________________________________
 FOR OFFICE USE ONLY
______________________________________________________________________
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices and Office Policy, but acknowledgement could not be obtained because:
___  Individual refused to sign.
___  Communication barriers prohibited obtaining the acknowledgement.
___  An emergency situation prevented us from obtaining acknowledgement.
___  Other (please specify)________________________________________________

Patient Name:___________________________________________________________
Other patient names if signing for family members as well:
______________________________________________________________________
______________________________________________________________________