Taking Blood Thinners
Drug or Alcohol Addiction
I authorize my dental health information be released to the following person:
I acknowledge the receipt of the Notice of Privacy Practices Below: (printed copy available upon request)
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION PLEASE REVIEW IT CAREFULLY
USES AND DISCLOSURES OF HEALTH INFORMATION
The following describes how information about you may be used in this dental office:
QUESTIONS AND COMPLAINTS
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the HHS.
to Dr. Christopher Clark's office.
Digital copies can be sent to email@example.com
Dr. Christopher Clark28321 Kensington Ln.Perrysburg, OH 43551