new patient New Patient Form Please enable JavaScript in your browser to complete this form. - Step 1 of 5First Name *Last Name *Phone *EmailDate of birthAddressTreatment for *Treatment for...ChildrenAdultsHow did you find us?How did you find us?PatientFriendDentistWebsiteInstagramFacebookGoogleTikTokYouTubeOtherWho referred you to our clinic Other?Reason for seeking treatmentNextMother / Guardian Details (for children only)Mother First NameMother Last NameMothers Email Mothers PhoneMothers Address Mother Marital StatusSingleMarriedSeparatedDivorcedOtherMother OccupationFather / Guardian Details (for children only) Fathers First NameFathers Last NameFather EmailFathers PhoneFather Address Father Marital StatusSingleMarriedSeparatedDivorcedOtherFather OccupationSpouse InformationSpouse Marital StatusSingleMarriedSeparatedDivorcedSpouse OccupationSpouse First NameSpouse Last NameSpouse PhonePreviousNextPatient’s DentistDo you have any oral health problems? If yes, please mention.Do you follow on daily basis a pharmaceutical treatment? If yes, which one?Do you have any pharmaceutical allergy? If yes, please mention the medications that cause allergy.Do you suffer from other medical problems? If yes, please mention.PreviousNextUSE OF PATIENT’S INFORMATION Laspos Orthodontic Center, in accordance with the Safeguarding and Protection of the Patients’ Rights Law of 2004, 1(I)/2005, is responsible to keep updated medical records for each patient which, among others include details that identify the patient's identity, the treatment he or she receives, and his or her previous medical history. Furthermore, we inform you that Laspos Orthodontic Center has taken all the required measures to fully comply with the European General Data Protection Regulation 2016/679 as well as with the Protection of Individuals Against the Processing of Personal Data and the Free Movement of such Data Law of 2018, 125(I)/2018. The retaining period of personal data collected is provided by the Protection of Individuals Against the Processing of Personal Data and the Free Movement of such Data Law and the European General Data Protection Regulation 2016/679. This retaining period may be extended if financial / legal disputes are pending and if the data are used for scientific or historical research purposes or for teaching purposes or for statistical purposes where we will obtain your consent and all appropriate measures that will no longer allow your identification. The personal data collected are the necessary prescribed by law in order to offer you the appropriate treatment and which are kept in written and / or electronic form and are part of your medical records that show the progress of your treatment. Such data may only be disclosed to members of the staff of the Laspos Orthodontic Center and/or its Associates for the purpose of providing appropriate treatment and which are bound by confidentiality obligations. Laspos Orthodontic Center may share information with third parties regarding your medical records if one of the following reasons apply: You have given us written consent to transfer information to a specific destination. Sharing of information is made to another competent health service provider for treatment purposes. Non-identifiable information and statistical data may be disclosed for publication in medical journals or for research or teaching purposes. We are obliged under any lagislation to do so. We have been instructed by a Court of Law to do so. Concealing the information entails serious risk of harm to the health or physical integrity of yourself or any other person or involves serious risk to the society in general. Your rights regarding medical records: Right to be informed Right to access and obtain a copy of medical information and to receive clarifications which are stored in medical records as well as updating, correcting, deleting and blocking files due to inaccuracies and deficiencies. The right to access may be restricted, denied or suspended in certain circumstances. Right to be forgotten Right to withdraw consent to any of the terms of processing your personal data. To the extent permitted by applicable law and regulations, we will review your request and inform you accordingly. Select one *Patient is adult : I understand and acknowledge the above information and I consent to the processing of my personal data in accordance with the above.Patient is minor: I am the father/mother of the above mentioned patient and I understand and acknowledge the above information and I consent to the processing of the personal data of my child in accordance with the above.PreviousNextI explicitly and without any prejudice declare, that after I have been informed sufficiently with simple, clear and understandable way everything concerning the keeping and processing of my/my child’s personal data by Laspos Orthodontic Center referred to from now on as the "Clinic", I give my explicit and unambiguous consent to the Clinic through its employees and/or representatives to photograph my/my child’s face at regular intervals in order to reflect the change in my/his/her face and/or my/his/her denture after the treatment I received from the Clinic. Further I expressly give my consent in order the Clinic to maintain and/or process my /my child’s above personal data for the following purposes:1) Information and/or promotion and/or update and/or for other related purposes to the public regarding the services and/or products offered by the Clinic, treatments that are used, final results and anything else that is relevant to the services and products used at various times, via the website and/or social media that the Clinic maintains, but also elsewhere worldwide the Clinic is requested to present various clinical cases through photos at all stages of the treatment that I received from the Clinic. *I consentI do not consent2) To display the Data Subject's photo on arrival at the clinic in a monitor at the entrance of the clinic so that its noticeable that the data subject has been in queueto be served by the clinical and office personnel and with the completion of the visit the photo is deleted from the screen *I consentI do not consentHereby I agree to all of the above and hereby I declare that I have not and will not have in the future any demands in relation to the use of the above mentioned photos.PreviousSubmit
