Consent Form

CONSENT TO THE DENTAL OFFICE

I consent to your office's collection, use and disclosure of information about me for the following purposes:

This office will collect, use and disclose information about you for the following purposes.

1. to deliver safe and efficient patient care

2. to identify and to ensure continuous high quality service

3. to assess your health needs

4. to provide health care

5. to advise you of treatment options

6. to enable us to contact you

7. to establish and maintain communication with you

8. to offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care generally

9. to communicate with other treating health-care providers, including specialists and general dentists who are the referring dentists and/orperipheral dentists

10. to allow us to maintain communication and contact with you to distribute health-care information and to book and confirm appointments

11. to allow us to efficiently follow-up for treatment, care and billing

12. for teaching and demonstrating purposes on an anonymous basis (e.g. intraoral photographs)

13. to complete and submit dental claims for third party predetermined of benefits and payment

13. to comply with legal and regulatory requirements

13. to permit potential purchasers, practice brokers or advisors to evaluate and audit the dental practice

14. to invoice for goods and services

14. to process credit card payments

I have read and agree

Fulll name *

Date (mm/dd/yyyy) *

Signature (to be signed in the office)