Brampton Dentist

Consent Acknowledgment

Having read and understood the PRIVACY STATEMENT FOR PATIENTS, I consent to the collection, use and disclosure of my personal information as presented in the STATEMENT.

I Agree

I Disagree

Your Name:

Date of Birth:

Email:

EDI Claims Consent

I authorize release; to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to Dr. Panna Mistry.

I Agree

I Disagree

Assignment Claims Consent

I hereby assign my benefits, payable from claims submitted electronically, to Dr. Panna Mistry and authorize payment directly to her.

I Agree

I Disagree

Text and/or Email Consent

I acknowledge Dr. Panna Mistry may contact me via text messaging and/or email for confirmation of upcoming appointments, reminders, birthday greetings, etc.

I Agree

I Disagree

Patient/Parent/Guardian Signature

Please make sure you've filled out all of the required fields.