HIPAA Notice Receipt Form

**Please read our Notice of HIPAA Privacy Practices before filling out the form below.**

You may fill out the Acknowledgement of Receipt of Notice of Privacy Practices online and submit it to our office, or download, print, and fill out a PDF copy of the form to bring with you to your next appointment.

Download PDF – HIPAA Notice Receipt Form

Acknowledgement of Receipt of Notice of HIPAA Privacy Practices

**You May Refuse to Sign This Acknowledgement**

  • By providing a mobile number, I agree that Andros Orthodontics may send me automated appointment and dental marketing messages at the number I provided above. I understand my consent is not required for purchase.

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