| I have received a copy of Center for Plastic Surgery Privacy Policy. | ||||||||
| Printed Name | Date | |||||||
| Signature | Date | |||||||
| Dr. Dell P. Smith, M.D is a member of the AAAASF. For accreditation of our | ||||||||
| surgical facilities your chart may be subject to random review by another a | accredited | |||||||
| surgeon. As always, your health care is kept in the strictest confidence and the | ||||||||
| examining surgeon has pledged confidentiality. | ||||||||
| Signature | Date | |||||||