Improving Smiles
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Notice of Privacy Practices

Robert C. Doshier D.D.S. P.A.
Acknowledgement of Receipt of
Notice of Privacy Practices

You may fill out and submit this form on our Web site! Or, if you have concerns about providing information via the internet, fill it out, and print it prior to an appointment. Then bring it with you to your first visit to save time when you arrive.

**You May Refuse to Sign or Send This Acknowledgement**

I, , have received a copy of this office's Notice of Privacy Practices.


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You may fill out and submit this form on our Web site! Or, if you have concerns about providing information via the internet, fill it out, and print it prior to an appointment. Then bring it with you to your first visit to save time when you arrive.



  

Robert C. Doshier, D.D.S., P.A. • 125 Sisco Street, Harrison, Arkansas 72601 • (870) 741-8551
E-mail: bdoshier@doshierdds.com • www.doshierdds.com

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