Receipt of Notice of Privacy Practices by fanzhongqing

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									                      St. Croix Plastic Surgery & MediSpa
                             Dr. Robert F. Centeno
                                 12 Beeston Hill
                            Christiansted, VI 00820
                                  (340-719-2777




                          Receipt of Notice of Privacy Practices
                            Written Acknowledgement Form




I, ________________________________, have received a copy of St. Croix Plastic Surgery &
MediSpa’s Notice of Privacy Practices.




________________________________                       __________________
      Signature of Patient                                   Date

								
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