FormsRelease of Records Notice of Privacy Practices Acknowledgement of Privacy Practices Authorization to Share Information Form New Patient Survey New Patient Information Patient Health History – Adult Patient Health History – Child Testimonial Release Form *You May Refuse to Sign This Acknowledgement* Giordano DentaI/Southern Tier TMJ & Sleep Therapy 864 Hooper Road Endwell, NY 13760 View the Notice of Privacy Practices HereI have received a copy of this office's Notice of Privacy Practices.Name:* First Last Date* For Office Use OnlyWe attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual Refused to Sign Communication barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please specify) If other, please specify here:Electronic Signature (E-Signature) AgreementBy selecting the "I Accept" button, you are signing this Release of Records electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Release of Records. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You also represent that you are authorized to sign this Release of Records for all persons listed on this form.*I AcceptElectronic Signature:Name* First Last Today's Date* NameThis field is for validation purposes and should be left unchanged.