Adult Record & Photo Consent

Name: Ipswich Orthodontics
Telephone: 07 3812 0865

Fields marked * are required.

Record release consent form

In accordance with the Privacy Act 2000, your written consent must be obtained before confidential information contained in your dental records may be released to another party.

Your privacy is important to us. The privacy act contains a set of principals for handling personal information in a confidential and secure manner.

We will only release your personal information to other Health care providers for care and continuation of your Orthodontic treatment, while you are being treated with us.

Do you give consent to the release of my dental records and contact details to my dental practitioner / dental specialists/ medical practitioner, or any other related health care professionals during the time being treated by Ipswich Orthodontics? * Yes No

Photo release consent form

Ipswich Orthodontics take photos for records, these photos may be used publicly for promotion, study and exemplary images.

I understand that the images may be used in Orthodontic presentations, websites, and social media.

I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

Do you give permission for these to be used for any other reason than records? * Yes No

I understand that;

The records may be emailed/posted to a nominated address.
Initials Records received by emailed may not be as secure as receiving the records personally.
Ipswich Orthodontics accepts no liability for the records once they leave the practice.
Ipswich Orthodontics accepts no liability for the records if they are accessed by unauthorized persons during transit or in any manner whatsoever without limitations.
I can ask for the copy of the records to be provided to me personally or by post if I am sufficiently concerned about email security.

Retention of documents relating to your care and agreement. By signing this, you understand and agree that scanning the original signed document and storing it in electronic form, has the same force and effect as the original signed document.

Patients Name*

Date of Birth*

Contact Number*

Date*

Patients Signature