GDPR consent form

GDPR consent form

Under the Dutch implementation of the General Data Protection Regulation (AVG/GDPR), we ask you to sign this form once. The rules around the protection of personal data have been tightened.

Our privacy statement is available on the website. You can withdraw or change your consent at any time.

To treat you as a patient, we need to process your personal, insurance and medical data and record your dentist and GP (see questions 1, 2 and 3 below, marked with *). Without this information we unfortunately cannot provide treatment.

Your details

Fill in your details as they appear on your ID.

9 digits, shown on your Dutch ID

Required consents

Without these three consents we cannot provide treatment. Marked with *.

Do you consent to the use of your personal data, such as your name, address, phone number, BSN, date of birth, insurance details and email address, in your record?*
Do you consent to the recording of your medical and medication data?*
Do you consent to recording your dentist and GP?*

Information exchange with other care providers

For continuity of care we ask permission to coordinate with your previous providers.

Do you consent to email contact with your dentist and/or previous dental hygienist (for the benefit of your treatment)?
Do you consent to requesting patient data, such as x-rays, from your dentist and/or previous dental hygienist (for the benefit of your treatment)?

Email contact with you as a patient

Indicate for which topics we may contact you by email.

Do you consent to email contact with you as a patient?
If yes, you consent to the following options:
Appointment reminders or confirmations
Booking or rescheduling appointments
Recall for check-up or treatment
Copy of invoices (on request)
Payment reminders
Cost estimates in advance

Additional communication and preferences

Optional. The items below go beyond the basic form.

Do you consent to appointment reminders by SMS?
Do you consent to short messages via WhatsApp?

Signature

By entering your name and ticking the confirmations, you sign the form digitally.

Identical to your name at the top