Asmath Noor, DDS, MDS

Norwalk Village Dental Center- 11274 E, Firestone Blvd, Norwalk, CA 90650

562-863-8600

Acknowledgement of Receipt Notice of Privacy Practices

Norwalk Village Dental Center
11274 Firestone Blvd.
Norwalk, CA 90650
Tel: 562-863-8600
Fax: 562-863-8393

By signing below I acknowledge that I have read or reviewed the Notice of Privacy . I agree with the terms of this notice and my right under this notice . By signing below I consent for the use of my personal health information for treatment, payment, and operations and other uses as described in the privacy notice . I also understand that I have the right not to sign this agreement.

Patient Name:
E-mail
Cell Phone

Patient's Signature:

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Date:
Relationship to Patient:

If we are unable to get your acknowledgment then our office will make a notation as to the reason why it was not obtained.

Reason why acknowledgment was not obtained

Staff Name
Date