Patient Consent Forms

Completion of these forms is required for all new patients.

They are combined into this 1 page so you can easily complete them online, with a computer or mobile device. Your response will be submitted to us securely.

If you have any questions, please give us a call.

Step 1 of 2

Patient Consent for Photographs and/or Radiography

Patient's name *

First

Last

Patient's birthdate (MM/DD/YYYY) *//

I am... *

The patient
An authorized person acting on behalf of the patient

I hereby consent to and authorize Authentic Orthodontics and its employees to record by means of still photographs, radiography (x-ray) and/or video of the above named patient and to reproduce, exhibit or publish these works for the purposes set out herein.

For use by our office and any of your other health care providers for the purpose of diagnosis and documentation of treatment progress

I hereby waive any, and all claims which I may at any time have against Authentic Orthodontics or its employees, in any matter whatsoever relating to the said photographs.

I represent that I am the parent/person having lawful custody of the above named patient. I hereby consent to the foregoing on the patient’s behalf. I understand that I can withdraw my consent at any time and acknowledge that in order to do so, I must provide written notice to Authentic Orthodontics.

I have read and agree to the information above *

Signature *

Orthodontic Office Personal Information Consent Form

We are committed to protecting the privacy of our patients and to utilizing all personal information in a responsible and professional manner. This document summarizes the personal information that we collect, use and disclose. In addition to the circumstances described in this document, we also collect, use, and disclose personal information when permitted or required by law.

Personal and Contact Information

We collect information from our patients such as names, home addresses, home/cell numbers, and e-mail addresses for the following purposes: (collectively referred to as “Contact Information”).

To open and update patient files
To invoice patients for orthodontic services, to process credit card payments, or to collect unpaid accounts
To process claims to assist patients in receiving reimbursement from third-party health benefit providers (insurance companies) To send reminders to patients concerning the need for further orthodontic examinations or treatment
To send patients informational material about our orthodontic practice

Contact information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of orthodontic treatment.

Financial information will be collected in order to make arrangements for the payment of orthodontic services.

Health History and Medical Information

We collect information from our patients about their health history, their family health history, physical condition, and all medical and dental treatments. (Collectively referred to as “Medical Information”). Patients’ medical information is collected and used for the purpose of diagnosing dental and orthodontic conditions and providing orthodontic treatment.

Patients’ Medical Information is disclosed:

To third party health benefits providers and insurance companies for the benefit of pre-authorization for orthodontic treatment
To other dentists and dental specialists where we are seeking an additional opinion and the patient has consented to us obtaining this second opinion
To other dentists and dental specialists if the patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment
To other dentists and dental specialists who have asked us, with the consent of the patient, to provide a second opinion
To other health care professionals such as physicians if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or treatment.

If we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted access as part of the due diligence process to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information.

Dentists are regulated by the Alberta Dental Association and College which may inspect our records and interview our staff as part of its regulatory activities in the public interest.

I consent to the collection, use, and disclosure of the patient's personal information as set out above. *

Signature *