Home
Our Services
Adult Orthodontics / Clearcorrect
Smile Makeover
Treatment for headaches
Nervous patients
Children’s Orthodontics / Myobrace
Teeth whitening
Dental Treatment
Mouthguards
Families
Implants
Crowns
Root canal treatment
Removal of silver fillings
Oral Hygiene
Clearcorrect
Smile Gallery
Adult Orthodontics / Clearcorrect
Children’s Orthodontics / Myobrace
Composite Bonding
Dental Implants
Smile Makeovers
Tooth Whitening
About Us
Blog
Contact Us
Online Booking
Home
Our Services
Adult Orthodontics / Clearcorrect
Smile Makeover
Treatment for headaches
Nervous patients
Children’s Orthodontics / Myobrace
Teeth whitening
Dental Treatment
Mouthguards
Families
Implants
Crowns
Root canal treatment
Removal of silver fillings
Oral Hygiene
Clearcorrect
Smile Gallery
Adult Orthodontics / Clearcorrect
Children’s Orthodontics / Myobrace
Composite Bonding
Dental Implants
Smile Makeovers
Tooth Whitening
About Us
Blog
Contact Us
Online Booking
Patient Consent To Process Personal Information
Home
>
Patient Consent To Process Personal Information
Dr. Christa Engelbrecht Dental
Patient Consent to process PERSONAL INFORMATION
Consent
(Required)
I agree to the privacy policy.
I hereby consent to the processing of my personal information contemplated in the Protection of Personal Information Act No 4 of 2013, by Dr. Christa Engelbrecht, the practice staff, and third parties with whom Dr. Christa Engelbrecht has a contractual relationship (eg Accountant and Auditor) for the following purposes:
a) Treating and managing me in terms of a doctor-and-patient relationship;
b) The administration of the contractual relationship between myself and Dr. Christa Engelbrecht
c) Communicating with third parties who have undertaken to indemnify me for the costs of my treatment and management or part thereof including medical schemes and their administrators where relevant; and
d) Collecting monies outstanding from me.
Patient Name
(Required)
First
Last
Date
(Required)
MM slash DD slash YYYY
Signature
(Required)
Name - if signed on behalf of a minor
First
Last