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Home - Hampton Smile - Dr. Sicurelli€¦ · Hampton Smile Dental P.L.L.C. 157 Wickapogue Road Southampton, New York, 11968 AUTHORIZATION AND CONSENT TO SEND UNENCRYPTED PATIENT INFORMATION

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Page 1: Home - Hampton Smile - Dr. Sicurelli€¦ · Hampton Smile Dental P.L.L.C. 157 Wickapogue Road Southampton, New York, 11968 AUTHORIZATION AND CONSENT TO SEND UNENCRYPTED PATIENT INFORMATION

Page 2: Home - Hampton Smile - Dr. Sicurelli€¦ · Hampton Smile Dental P.L.L.C. 157 Wickapogue Road Southampton, New York, 11968 AUTHORIZATION AND CONSENT TO SEND UNENCRYPTED PATIENT INFORMATION

Page 3: Home - Hampton Smile - Dr. Sicurelli€¦ · Hampton Smile Dental P.L.L.C. 157 Wickapogue Road Southampton, New York, 11968 AUTHORIZATION AND CONSENT TO SEND UNENCRYPTED PATIENT INFORMATION

Page 4: Home - Hampton Smile - Dr. Sicurelli€¦ · Hampton Smile Dental P.L.L.C. 157 Wickapogue Road Southampton, New York, 11968 AUTHORIZATION AND CONSENT TO SEND UNENCRYPTED PATIENT INFORMATION

Page 5: Home - Hampton Smile - Dr. Sicurelli€¦ · Hampton Smile Dental P.L.L.C. 157 Wickapogue Road Southampton, New York, 11968 AUTHORIZATION AND CONSENT TO SEND UNENCRYPTED PATIENT INFORMATION

Page 6: Home - Hampton Smile - Dr. Sicurelli€¦ · Hampton Smile Dental P.L.L.C. 157 Wickapogue Road Southampton, New York, 11968 AUTHORIZATION AND CONSENT TO SEND UNENCRYPTED PATIENT INFORMATION

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