I certify that I have received a copy of Prime Pediatric Dentistry’s Notice of Privacy Policy.

I give full permission for the below listed, to have complete access to patient listed above. This includes, but is not limited to: chart details, x-rays, and dental restoration needed. I also give full authority to make any decisions necessary for any treatment planned in relation to the patient’s dental needs from Prime Pediatric Dentistry.

Staff Will Complete This Section If Patient’s Signature Not Obtained.

Our office made a good faith effort to obtain a Written Acknowledgement or Receipt of our Notice of Privacy Practices, but it could not be obtained for the following reasons.