• Patient Consent Form

  • I agree that Dr. John Doe and Associates can collect, use and disclose personal information as set.

    I, the undersigned, certify that I have provided an accurate and complete personal and medical/dental history and I have not knowingly omitted any information. I have given complete answers to all questions regarding my medical/dental history. I authorize the dentist to preform diagnostic procedures and treatment as necessary, and consent to my physician being contacted if necessary.

    I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for the payment of all services rendered on my behalf or on behalf of the dependents or charges.

    I have reviewed the above information that explains how your office will use my personal information and the steps your office is taking to protect my information.

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  • Privacy Information Act January 2015

    Patient consent Form: For collection, use and disclosure of personal Information.

    Federal Legislation, entitled the Personal Information Protection and Electronic Documents Act (PIPEDA), now applies to the private sector. Privacy of your personal information is an important part of our office providing you with quality dental care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open as possible about the way we handle your personal information. It is important to us to provide this service to our patients.

    In this office Dr. John Doe acts as the Privacy Information Officer.

    All staff members who encounter your personal information are aware of the sensitive nature of the information you have disclosed to us. They are all trained in the appropriate uses and protection of your information.

    • Only necessary information is collected about you
    • We only share your information with your consent
    • Storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols
    • Our privacy protocols comply with the privacy legislation, standards of our regulatory body, The Royal College of Dental Surgeons of Ontario and the law.

    By signing the patient consent form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for administrative purposes. Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and the defense of a legal issue. Our office will not under any conditions supply your insurer with your confidential medical history. In the event this kind of request is made, we will forward the information directly to you for review, and for your specific consent.

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