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1316 SW 13TH AVENUE PORTLAND, OR 97201 (503) 235-0555 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I have received a copy of the Notice of Privacy Practices of this office. CONSENT FOR
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Cosmetic Dental Arts Inc is a dental clinic specializing in cosmetic dentistry services.
The owner or authorized representative of Cosmetic Dental Arts Inc is required to file the necessary paperwork.
To fill out the necessary paperwork for Cosmetic Dental Arts Inc, the owner or authorized representative must provide information about the business, its services, and financial details.
The purpose of Cosmetic Dental Arts Inc is to provide high-quality cosmetic dentistry services to patients.
Information such as business details, services offered, financial information, and any other relevant details must be reported on the paperwork for Cosmetic Dental Arts Inc.
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2002 13TH PATIENTPLEASE ReservedReproduction NW ADANW PORTAND TEASDALE revocation disclosures duplication SW accompanies reliance revisions ACKNOWLEDGEMENT healthcare spouses Revoke obtaining constitute Specify barriers DISCLOSURE dentists revoked revised

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