Patient Intake & Consent Form

Patient Intake & Consent Form
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com

Gender*

MaleFemalePrefer not to say
Referring Dentist / Doctor*
Is there a chance you may be pregnant?

YesNo
Do you have medical condition, injury or require special assistance?

YesNo
Please Explain:

Consent to Dental Imaging Services

I consent to the diagnostic imaging services performed by Orbit Imaging, including the collection, use, and disclosure of my personal health information for the purpose of diagnosis, treatment, and coordination with my referring healthcare provider.

I understand the following:

My personal information is collected and handled in accordance with Orbit Imaging’s Privacy Policy. https://www.orbitimaging.com/privacy-policy-1

My health information may be stored on secure servers located in Canada and is subject to privacy laws.

I may withdraw my consent at any time, subject to legal or contractual obligations, by contacting the Privacy Officer at jcarr@orbitimaging.com.
Signature of Patient (or parent or guardian if applicable)*

Clear
Date*

MonthDayYear
Date
Should be Empty: