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)
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