Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.
I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and healthcare operations.
Cancellation Policy: At Newbury Dental, we pride ourselves in offering outstanding customer service. This includes providing a team of highly qualified health care professionals and an efficient delivery of care. In return, we appreciate a commitment from clients to be responsible for attending their appointments. Patients who fail to show for their appointments or who cancel without 48 hours notice will be subject to a $75 fee for missing up to one hour of reserved time and an increased amount for missing longer appointments.
*As with certain office policies, there will inevitably be exceptions that will be dealt with on a case-by-case basis.
Our commitment at Newbury Dental is to provide our patients with exceptional care and service. We thank you for your time and cooperation!
Photography Consent: Newbury Dental may take photographs and/or videos of your teeth and jaws, before, during, and after completion of any dental treatments. These photos and/or videos may be used for dental records, communication with other health professionals, research, education, patient counselling and marketing material. Written consent will not be obtained if the photographs and/or videos are used anonymously, and will only be required if your name or other identifying information will be revealed.