Doctor Consent Agreement
I, the undersigned clinician certified in the country provided in my registration, (hereafter “Doctor”) upon having read and understood the content below, agree and consent as follows:
1. Doctor is submitting to ClearCorrect, (“ClearCorrect”):
a. Patient record numbers, which ClearCorrect will only use for verification of payment purposes and will subsequently delete from its systems;
b. Information, documentation and materials relating to completed treatments of adults or patients within the applicable Instructions for Use documents for the ClearCorrect clear aligner system including but not limited to, photographs, Treatment Setup records, radiographs (x-rays), testimonials, patient records, models, PVS impressions, treatment summary form and demographic information (“Patient Data”), for use in casebooks, treatment galleries, ClearCorrect websites (including without limitation the ClearCorrect Case Gallery), clinical education publications, convention exhibits, presentations, advertising and any other marketing or promotional activities (which may be online or print), or the then currently titled ClearCorrect Program or other professional education program (the “Permitted Purpose”), together with information identifying me and identifying me as their treating doctor (“Doctor Data”); and
2. Doctor agrees and hereby represents and warrants that he or she has obtained from any patient whose data is included in the Patient Data a signed Patient Consent and Release Form in the form provided by ClearCorrect as well as any other documents which the Applicable Privacy Laws may require in order to obtain explicit consent from a Patient to the processing of their Patient Data for the Permitted Purpose signed by the patient and patient’s parent/guardian if patient lacks the legal capacity to sign, e.g. a minor, authorizing processing of their Patient Data, which includes a description of Personal Data (defined as any information relating to an identified or identifiable natural person which is one who can be identified, directly or indirectly, in particular by reference to an identification number or to one or more factors specific to his physical, physiological, mental, economic, cultural or social identity) and authorizing ClearCorrect’s use of that Patient Data for the Permitted Purpose without any compensation (a) and (b) collectively, “Submissions”.
3. Regarding the Submissions:
ClearCorrect and the Doctor acknowledge that Submissions include Personal data and can include special categories of data, such as health-related data.
Doctor shall comply with the privacy and data protection laws applicable in the state and country in which the Doctor practices (the “Applicable Privacy Laws”) when processing personal data relating to patients, including the processing of Patient Data, and in the collection and transfer of Submissions.
ClearCorrect will only process Submissions for the Permitted Purpose and will do so as a controller in full compliance with the Applicable Privacy Laws.
At no time will Doctor identify any individual by name or provide his/her initials in the Patient Data, save for providing the patient number for cross-checking by ClearCorrect, and, if Doctor inadvertently does so, ClearCorrect must not use or disclose such details in the Submissions.
Doctor warrants and represents that at the point of submission the Submission belongs to him/her, and no other person or entity holds rights to the Submission except the patient. Doctor shall indemnify, defend and hold harmless ClearCorrect, its parent, subsidiaries, affiliates, directors, officers, employees, agents and agencies from any and all claims, demands and losses of any kind, including costs, damages, payments penalties, interest, fines and compensation, arising from or in connection with its use of the Submissions, as far as permitted by law and with the exception of any loss cause to ClearCorrect as a result of negligence or willful misconduct on the part of ClearCorrect.
4. Doctor’s Personal Data:
Doctor agrees and consents to ClearCorrect processing their name, contact details and any other personal data that doctor provides during their participation in the treatment gallery, or the then currently titled global case gallery program or other professional education program for the permitted purposes which include education program for the permitted purposes which include educational and promotional purposes. This may require that the doctor’s name, image, contact information and country of practice is made publicly available in both online and printed publications alongside patient data.
5. Doctor understands the purpose and scope of this Agreement, and further understands that he/she is free to refuse consent to the use of their Personal Data as set forth above or withdraw their consent at any time and that where his/her Personal Data has been used in print his/her refusal or withdrawal will not have a retroactive effect. Also, Doctor has the right to access their Personal Data held by ClearCorrect and to request its correction or erasure but acknowledge that where Doctor Data has been used in print or has been copied by an outside third party from an earlier online version my refusal or withdrawal will not have a retroactive effect. To this end, Doctor may contact:
ATTN: Privacy/Case Gallery
21 Cypress Blvd., Ste. 1010,
Round Rock, TX 78665
6. Subject to the acceptance by ClearCorrect of the Doctor’s Submissions, all documentation and materials that are included in the Submissions, and all intellectual property rights relating to or covering such documentation and materials, shall be the sole property of ClearCorrect, save that where applicable law does not permit the assignment to ClearCorrect of Doctor’s Submissions. Doctor hereby licenses without limit in time or jurisdiction, and without right to terminate, the non-exclusive right to take copies, and use for any purpose the Doctor’s Submissions, including the right to sublicense to and share the information with third parties, e.g. advertising agencies, marketing partners, etc.
7. Doctor on behalf of doctor and each of its successors, assigns, heirs, beneficiaries, and all others claiming by, under, or through doctor, hereby irrevocably assigns to ClearCorrect to the fullest extent permitted by law all rights subsisting in the submissions, including any copyright or moral rights. Doctor hereby releases or waives any moral rights existing in the submissions to the fullest extent permitted by law.
Doctor further acknowledges and agrees that upon creation of the treatment gallery by ClearCorrect, or the then currently titled global case gallery program, or other professional education program, ClearCorrect shall own all right, title and interest in and to the copyright and all moral rights in such gallery or program.
8. ClearCorrect shall not be under any obligation to use or exploit the accepted Submissions.
This Agreement, its subject matter and its formation (and any non-contractual disputes or claims) are governed by the State of Texas. The parties irrevocably agree to the exclusive jurisdiction of the courts of Williamson County, State of Texas.