MELISSA E. RINCK D.D.S.
750 LAS GALLINAS AVE., #215
SAN RAFAEL, CA 94903
(415) 479-4977
Patient Acknowledgement of Receipt of Dental Materials Fact Sheet

I,
acknowledge I have received from Melissa E. Rinck, D.D.S. & Judy Chau, D.D.S., a copy of the Dental Materials Fact Sheet dated October 2001.