Louis J, Russo Jr., DDS, PA
Jonathan L. Nicozisis, DMD, MS
601 Ewing Street, B-12
Princeton, NJ 08540
Practice Limited to Orthodontics
Check any of the following for which you have been treated:
Jonathan L. Nicozisis, DMD, M.S.
Louis J. Russo, Jr., DDS
601 Ewing Street
Princeton, New Jersey, 08540
(609) 924 –3271
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consent. I understand that this organization has the right to change its Notice of
Privacy Practice from time to time and that I may contact this organization at any
time at the above address to obtain a current copy of the Notice of Privacy Practices
I understand that I may request in writing that you restrict how my private
information is used or disclosed to carry out treatment, payment or health care
operations. I also understand you are not required to agree to my requested
restrictions, but if you do agree then you are bound to abide by such restrictions.
I understand that I may revoke this consent in writing at any time, except to the
extent that you have taken action relying on this consent.