Patient Consent Form: For Collection, Use And Disclosure Of Personal Information

  • 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 and transparent as possible about the way we handle your personal information. It is important to us to provide this service to our patients. Do not hesitate to discuss our policies with any member of our office staff.

    How our office collects, Uses and Discloses patient’s personal information.


    All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. Our staff are trained in the appropriate uses and protection of your information. Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined here how our office is using and disclosing your information.

    The office will collect, use and disclose information about you for the following purposes:

    • To deliver safe and efficient patient care.
    • To identify and to ensure continuous high quality care
    • To assess your health needs
    • To provide health care
    • To advise you of treatment options
    • To establish and maintain communication with you
    • To offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care generally
    • To communicate with other treating health-care providers, including specialists and general dentists who are the referring dentists and/or peripheral dentists
    • To allow us to maintain communication and contact with you to distribute health-care information and to book and confirm appointments
    • To allow us to efficiently follow-up for treatment, care and billing
    • For teaching and demonstrating purposes on an anonymous basis
    • To complete and submit dental claims for third party adjudication and payment
    • To comply with legal and regulatory requirements, including the delivery of patient’s charts and records to the Royal College of Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of the regulated Health Professional Professions Act
    • To comply with agreements/undertakings entered into voluntarily by the member with the Royal College of Dental Surgeons of Ontario, including the delivery and/or review of patient’s charts and records to the college in a timely fashion for regulatory and monitoring purposes
    • To permit potential purchasers, practice brokers or advisors to evaluate the dental practice
    • To allow potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale
    • To deliver your charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability and quantify damages, if any
    • To prepare materials for the Health Professions Appeal and Review Board (HPARB)
    • To invoice for goods and services
    • To process credit card payments
    • To collect unpaid accounts
    • To assist this office to comply with all regulatory requirements to comply generally with the law


    By signing the consent section of this 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 the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance
    Your information may be accessed by regulatory authorities under the terms of the RHPA for the purposes of the RHPA for the purposes of the RCDSO, and for the defense of a legal issue" should be "Your information may be accessed by regulatory authorities under the terms of the RHPA for the purposes of the RHPA, for the purposes of the RCDSO, and for the defense of a legal issue.

    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. I know that your office has a Privacy Code, and I can ask to see the code at any time.