Acknowledgement of receipt of notice of



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Date conversion27.11.2016
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Kaveh Kanani, D.D.S



22030 Clarendon St Suite #102

Woodland Hills, CA 91367

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF

PRIVACY PRACTICES and Dental Materials Fact Sheet

Around the Corner Dental Health Spa/ Dr. Kaveh Kanani reserves the right to modify the privacy practices outlined in the notice.
I have received a copy of the Notice of Privacy Practices and Dental Fact Sheet for Around the Corner Dental Health Spa/ Dr. Kaveh Kanani, DDS

___________________________________________________________



Signature of Patient Date


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