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Phone: (831) 688-7878

Patient Acknowledgement of Receipt of Dental Materials Fact Sheet and Notice of Privacy Practices


As of January 1st, 2002, the Dental Board of California now requires that we distribute to our patients a copy of the Materials Fact Sheet. In addition, as of April 14th, 2003 the Health Insurance Portability and Accountability Act (HIPAA) requires that patients be given a copy of our Notice of Privacy Practice.


If you would, please print and sign below:

We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the state of California. This includes issues relating to your treatment, payment, and out health care operations. Your personal health information will never be otherwise given to anyone-even family members-without your written consent. You, of course, may give written authorization for us to disclose your information to anyone you choose for any purpose.


By signing this form, you acknowledge that you have received from this office (1) A copy of the Dental Materials Fact Sheet, and (2) Notice of Privacy Practices.


Patient's First Name: *

Patient's Last Name: *

Date: *


The person filing out form is: *

If signed by a Personal Representative of the patient, describe the representative's authority to act for the patient.

If Representative, Representative's Name:


Please type/sign with your full name.


Please wait, it may take a moment to submit your information.


Sam Christensen, DDS
General Practitioner

7545 Soquel Drive Suite C
Aptos, CA, 95003-3848
(831) 688-7878


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