HIPAA

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES

You may refuse to fill out this acknowledgement. By filling out this form, you are verifying that you have received a copy of this office’s Notice of Privacy Practices

I AM THE “PERSONAL REPRESENTATIVE” AND HAVE LEGAL AUTHORITY TO MAKE HEALTH CARE DECISIONS ABOUT THE FOLLOWING PATIENT:

Name*
First Middle Last
Authorization of additional disclosure:
I authorize the following individuals to have access to my health information.
Name/Relationship
Name/Relationship
Name/Relationship
I give Northgate Dental permission to leave phone messages on any of my phone contacts.*
- Yes
Please contact me personally and <strong>DO NOT</strong> leave messages*
- Yes
I give Northgate Dental permission to leave messages only on the following phone numbers:*
- Yes
Authorized Phone # for Messages
Authorized Phone # for Messages
Authorized Phone # for Messages
Authorized Phone # for Messages
CAPTCHA

Your smile is our passion, and experience is our power.

PHONE

(719) 488-2292

ADDRESS

1016 Middle Creek Parkway, Colorado Springs, CO, 80921-3754

EMAIL

info@northgatedentalcare.com

HOURS

Mon: 8:00am - 3:30pm

Tues: 8:00am - 4:00pm

Wed: 8:00am - 3:30pm

Thurs: 8:00am - 4:00pm

Fri-Sun: CLOSED

Book An Appointment

New Patient Forms

Authorization of additional disclosure:

Your smile is our passion, and experience is our power.