ACKNOWLEDGEMENT OF RECEIPT OF

NOTICE OF PRIVACY PRACTICES

Privacy Officer: Jenna Sherman (949) 493-7661

I hereby acknowledge that I received a copy of Henken Orthodontics’ Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that I will be offered a copy of any amended Notice of Privacy Practices at each appointment.

Signed: _______________________________________ Date: __________

Printed Name: _________________________________ Telephone: ______________________

If not signed by the patient, please indicate relationship:

r Parent or guardian of minor patient

r Guardian or conservator of an incompetent patient

r Beneficiary or personal representative of deceased patient

Name of Patient: _____________________________________________________

Henken Orthodontic Dental Corporation

Edmond H. Henken, DDS, MS w David M. Kennedy, DDS, MS

31882 Camino Capistrano # 200

San Juan Capistrano, CA 92675

(949) 493-7661

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1171 Puerta del Sol, #B

San Clemente, CA 92673

(949) 661-3336