Patient Consent Agreement
- 1. I release my treating doctor from the doctor-patient confidentiality obligations and hereby expressly agree and authorize my treating doctor to submit my orthodontic and related treatment records as well as information concerning my orthodontic medical history and my treatment with the ClearCorrect clear aligner system (specified below as “Product”) (which comprises information, documentation and materials relating to my completed treatment with the specified Product, photographs, Treatment Setup records, radiographs (x-rays), testimonials, models, PVS impressions, treatment submission form and demographic information but which does not identify me by name) (“Patient Data”), to ClearCorrect Operating LLC (along with its affiliates and subsidiaries listed below) (together “ClearCorrect”) for the purposes of a program or programs (“ClearCorrect Program(s)”), as described in Paragraph 5 (“Permitted Purpose”).
- 2. I understand that I am free to sign this consent form and that my treatment does not depend on me agreeing to the release of my Patient Data for the Permitted Purpose.
- 3. I understand that my Patient Data will be sent to ClearCorrect, only with my case number as identified in order for ClearCorrect to be able to verify that I am actually a ClearCorrect patient and the patient number will subsequently be deleted from the file. The Patient Data will only be publicly published without my name or initials and ClearCorrect will make every attempt to ensure my anonymity. I understand, however, that complete anonymity cannot be guaranteed, and somebody may be able to identify me nonetheless from, for example, photographs.
- 4. I understand that the ClearCorrect Case Gallery Program will involve my Patient Data (excluding identifiers such as my case number, name, or initials) being used by ClearCorrect in casebooks, treatment galleries (including publicly available, on-line galleries), ClearCorrect websites, clinical education publications, convention exhibits and presentations (which may be online, in person, or in print), or the then currently titled ClearCorrect Program or other professional education program without compensation to me.
- 5. By signing this document, I agree that ClearCorrect may use my Patient Data (excluding my patient record number, name, and initials) for advertising and any other marketing or promotional activities. This includes the right for ClearCorrect to sublicense to or share the information with third parties for the aforementioned purposes, to advertising agencies and marketing partners.
- 6. I understand that ClearCorrect may transmit or provide my Patient Data to its offices located outside my country of residence as well as to third parties also located outside my country of residence or region. These countries do not necessarily offer the same safeguards to protect my Patient Data as my national law. However, where ClearCorrect transfers my Patient Data outside my country of residence or region, ClearCorrect will provide adequate protection, as required by the applicable law.
- 7. ClearCorrect will only process Patient Data for the Permitted Purpose and will do so as a controller in full compliance with applicable laws in my jurisdiction.
- 8. I understand that I am free to refuse or withdraw my permission to use my Patient Data for the Permitted Purpose at any time and free of charge, but understand that where my Patient 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.
- 9. I have the right to request access to my personal data at any time and to request correction, removal or blockage thereof. To this end, or if I wish to withdraw my consent, I may contact ClearCorrect at:
ATTN: Privacy/Case Gallery
21 Cypress Blvd., Ste. 1010, Round Rock, TX 78665