Privacy Consent Form

I allow and provide consent to Nordic Dentistry to collect, use and disclose information about me for the following purposes:
To deliver safe and efficient patient care
To identify and to ensure continuous, high-quality services
To assess my dental health needs
To advise me of treatment options
To enable Nordic Dentistry to contact me directly
To establish and maintain communication with me
To offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care
To allow Nordic Dentistry to efficiently follow-up for treatment, care, and billing For teaching and demonstrating purposes on an anonymous basis
To complete and submit electronic and/or paper dental claims for third party adjudication, pre-approval where necessary, and payment
To permit dentists, practice brokers and/or advisors to evaluate the dental practice and conduct an audit in preparation for practice sale
To invoice for goods and services
To process credit card payments when there is a balance outstanding or when I call in and provide telephone authorization
To provide Nordic Dentistry with insurance details, so we may receive a dental breakdown of the coverage. You are also responsible for any differences not paid by the insurance company, on the same day as the service is rendered.
o If a patient’s account falls into arrears all reasonable collection fees will be the responsibility of the account holder, in addition to the arrears and possible service fee.
I authorize Nordic Dentistry to post/advertise pictures within the office and on social media of myself or my child/dependent.
I authorize release to my dental benefits plan administrator, information contained in claims submitted electronically.
This authorization shall continue in effect until authorize the communication of information related to the coverage of services described to the named dentist.

Patient Name:(Required)

First Last

Signature (of patient or parent/guardian):(Required)

Date(Required)