PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY
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 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 is available upon request.
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.
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 health care operations.
Parent’s approval by signature if patient is less than 18 years of Age. You are entitled to a copy of the consent after you sign it.
Media Release
I, the undersigned, do hereby consent and agree that Ovation Orthodontics , its employees, or its agents have the right to use photographs, artwork, designs, videotape, or digital recordings of me and to use these in any and all print/media/social media, now or hereafter known, and exclusively for the purposes of education and promotion. I further consent that my name and identity may be revealed therein or by descriptive text or commentary.
I do hereby release to Ovation Orthodontics and its agents and employees all rights to exhibit this work in print and electronic form publicly or privately. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used.
I understand that there will be no financial or other remuneration for recording me, using my likeness or my story, either for initial or subsequent transmission, playback, print, or electronic/social media.