We would Like to welcome You and your child to our office. Our mission is to enhance the lives of our patients and their families by providing exceptional orthodontic care with excellent customer a service in. a safe and inviting atmosphere.

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Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

Growth information for Patients Under 16 Years of Age

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Acknowledgement of Receipt of Notice of Privacy Practices

Saylor & Murphy Orthodontics

* You May Refuse to Sign This Acknowledgment*
I have received a copy of this office’s Notice of Privacy Practices.

Right to Revoke:

I have the right at any time to revoke this Acknowledgement for any reason. I have the right to sign this portionat a later time/dateof my choice to revoke my Acknowledgment.

I understand the information that I have given today is correct and to the best of my knowledge. I also understand that is information will be held in strictest confidence and that it is my responsibility to inform this office of any changes in my medical status. I authorize the staff to perform any necessary services that the patient may need during diagnosis and treatment.