Yardley PA Dental Care

301 Oxford Valley Road Suite 404-A, Yardley, PA, 19067

Patient Forms
  • (215) 493-1616
  • 301 Oxford Valley Road, Suite 404-A
  • Yardley, PA 19067
  • Yardley Dental Care
  • Acknowledgement of receipt of notice privacy practices

    you may refuse to sign

    i have received/reviewed a copy of this officer's notice of privacy practices.

    Signature of patient /parent or Guardian (if under age 18)

    office use only

    we attempted to obtain written aknowledgement of receipt of our notice of privacy practices. however acknowledgement could not to obtain because:

    communication barriers prohibited obtaining:

    other(specify):