GDPR Patient Consent Form

The following data is collected to facilitate your dental treatment. Any party receiving the information shall not use it for commercial purposes or release it to any party without your prior approval, for example we may share your information with a specialist with your consent.

Each patient has the right to request in writing, a copy of any personal data about themselves which is held and have amended any personal data which is incorrect, incomplete or misleading.

Each patient has the right to complain to the Data Protection Commissioner, email:, if you have any issues with how we have handled your data.

I understand that I may revoke this consent at any time by contacting Dr Eileen Blackwell. My consent will be updated as required.

I consent to the use of my personal details as set out above.

GDPR Patient Form

  • Date Format: MM slash DD slash YYYY

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