I moved three hours away, but I
insist on making the special trip to
Dr. Hellickson every 6 months. He
and his staff are the best!
Bradi Yaggie
News and Specials
We offer Zoom! Professional Whitening. Please click here for specials.

CAESY Online is a patient education learning program. Learn more about:
Download Our Newsletters

Acknowledgement of Receipt of Notice of Privacy Practices

03 of 03

**You may refuse to sign this acknowledgement
Would you like to sign this Acknowledgement of Receipt of Notice of Privacy Practices?Yes No


Please note that it is important to fill in all the fields before submitting. Thank you.

I acknowledge that I have received a copy of this office’s Notice of Privacy Practices.

*Patient Name :
  *Last Name

  Mid Name

  *First Name
*Signature :
Date :