I have received a copy of Dr. Keeter / Geiger / Ellsworth / Dizon's Notice of Privacy Practices and have read and understand this
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
By signing this form, you have reviewed and understand our Notice of Privacy Practices and give consent to use and disclose your protected health information
that may be used for treatment, payment or healthcare operations.
|May we phone, email, or send a text to you to confirm appointment?
|May we leave a message on your answering machine at home or on your cell?
|May we discuss your dental conditions with any persons other than yourself?
If YES, please list names below:
|If signing on behalf of patient, please complete the following: