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icon location at double resolution 2525 K Street, Suite 108 Sacramento, CA

Patient Appreciation Drawing Entry Form

First Name:*
Last Name:*
I made it to my appointment on:
I referred a new patient who made it to an appointment at the office:
[Enter Name of Referred Patient]:
I left a review on Facebook, Yelp, or Google
[Please indicate where]:
Do you authorize the potential use and disclosure of your name, photographic/video images, and/or testimonial for marketing purposes via social media and/or advertising by Rho Family Dentistry? By selecting "Yes" below, you understand that information disclosed pursuant to this authorization may be subject to redisclosure to this authorization may no longer be protected by HIPAA privacy regulations.:* YES
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Rho Family Dentistry, 2525 K Street, Suite 108 Sacramento, CA 95816 - (916) 562-2755 - rhofamilydentistry.com - 7/12/2024 - Page Phrases: dentist Sacramento CA -