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PROGRESSIVE DENTAL SOLUTIONS CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION SECTION A: PATIENT GIVING CONSENT Name: Address: Telephone:Email:Patient Number:Social Security Number:SECTION B:

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How to fill out consent for use i

01

Start by reading the consent form carefully and understanding all the information provided.

02

Fill in your personal details such as your name, address, contact information, and any other required information.

03

Make sure to tick or check the appropriate boxes indicating your consent or refusal for specific uses of your personal information.

04

If there are any sections or questions that you do not understand or are unsure about, seek clarification from the organization or individual requesting your consent.

05

Review the completed form and ensure all information is accurate and complete before signing and dating it.

06

Keep a copy of the signed consent form for your records or provide it to the relevant party as instructed.

Who needs consent for use i?

01

Anyone who is required to share or disclose their personal information to an organization or individual for a specific purpose may need to fill out a consent form.

02

This could include individuals participating in research studies, patients undergoing medical procedures, individuals signing up for online services, or anyone who wants to control the use of their personal information.

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