Fields marked * are required.
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.
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.
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.
By submitting this form, you are agreeing to our
13 South Street
07 3812 0865