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Louis J, Russo Jr., DDS, PA
Jonathan L. Nicozisis, DMD, MS
601 Ewing Street, B-12
Princeton, NJ 08540
(609) 924-3271
Practice Limited to Orthodontics
www.princetonorthodontics.net

ORTHODONTIC REGISTRATION & HEALTH HISTORY QUESTIONNAIRE

PLEASE COMPLETE BOTH SIDES. ANSWER ALL QUESTIONS.

BE ASSURED THAT ALL QUESTIONS ARE NECESSARY AND ALL ANSWERS WILL BE KEPT CONFIDENTIAL

MEDICAL HEALTH HISTORY

DENTAL HEALTH HISTORY

Princeton Orthodontics
Jonathan L. Nicozisis, DMD, M.S.
Louis J. Russo, Jr., DDS
601 Ewing Street
B-12
Princeton, New Jersey, 08540
(609) 924 –3271

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE

You may refuse to sign this acknowledgement

I have been informed of your Notice of Privacy of Practice containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this 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.