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3A Lansdowne Rd, Colwyn Bay

reception@thebayorthodontics.co.uk

Telephone:

01492 535 350

Opening Hours

Monday 08:00-07:00 PM Tuesday 08:00-07:00 PM Wednesday 8:30-05:30 PM Thursday 08:00-07:00 PM Friday 08:30 AM-03:30 PM Sat 08:30 -02:30 OCNL

Book Your Consultation

Don't wait any longer to achieve the smile you've always dreamed of. Book your consultation today!

3A Lansdowne Rd, Colwyn Bay

reception@thebayorthodontics.co.uk

Home Patient Consent Form

Patient Consent Form

For a person other than the patient to access dental appointments and/or records
Please enable JavaScript in your browser to complete this form.
Patient Details
Address

Details of person/people to be given access to the above named patient's information

Person 1
Address

Details of person/people to be given access to the above named patient's information

Person 2
Address

Your Consent

I, the patient, give consent for The Bay Orthodontics to discuss the following information with the person(s) named above
(please tick):

My past/future appointments (including to make/cancel appointments on my behalf)
My dental records (including dental history and current treatment and any other health records being processed by the practice)
My general account information (including payments made or due, my contact details and other details relating to the administration of my account)
My health insurance policy (including premiums made or due, my contact details and or other deductibles and details for policy renewals)

I understand that The Bay Orthodontics will accept this consent for a period of up to one year from the date of signature
and that I may withdraw this consent or request a change to these details at any time by contacting the practice.

Signatures

Completed by (please tick):

Relationship to patient (if signing on behalf of patient):To be completed where a parent or legal guardian is completing this form on behalf of a dependent aged15 years or younger.

Personal Information

We recognise that when you give us personal information (which includes health information) you’re trusting us to
take good care of it. Please see www.thebayorthodontics.co.uk/?page_id=4972 for more information about how
we collect, use and protect your data.