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Have you been hospitalized or had a major operation within the last 2 years?
Are you or could you be pregnant and/or breastfeeding?
Do you have, or have you ever had, a heart condition or tested positive for a disease that could affect your immune system? (e.g. leukemia requiring chemotherapy)
Did you ever have any of the following ?

CONSENT

COLLECTION OF PERSONAL INFORMATION

 

Privacy of your personal information is an important part of providing you with quality dental care. We understand the importance of protecting your personal information and we are committed to collecting, using and disclosing your personal information responsibly. We collect personal information for the following purposes and mandate:

  • Only necessary information is collected about you;

  • We only collect, use, and share your information with your consent;

  • Storage, retention and destruction of your personal information complies with existing legislation;

  • We continuously review our policies and privacy protection protocols on an ongoing, annual basis to ensure that we comply with our obligations under various provincial legislation;

  • We confirm that our privacy protocols comply with provincial privacy legislation and standards of our provincial regulatory body, as amended from time to time.

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

  • To deliver safe and efficient patient care and to identify and to ensure continuous high-quality service.

  • To assess your health and dental care needs and to advise you of treatment options.

  • To enable us to contact you and to establish and maintain communication with you.

  • To communicate with other treating health-care providers, including specialists and general dentists who are the referring dentists and/or peripheral dentists.

  • To maintain communication with you to provide health care information and to book/confirm appointments.

  • To allow us to efficiently follow-up for treatment, care and billing.

  • To comply with legal and regulatory requirements, including the delivery of patients' charts and records to our provincial regulatory body, in a timely fashion.

  • To invoice for goods and services and to process credit card payments.

  • To comply with our obligations under applicable federal and provincial privacy legislation.

By signing the consent section of this Patient Consent Form below, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes included herein. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance.

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 for your review, and for your specific consent. I have reviewed the above information that explains how your office will use and protect my personal information. I understand that I may withdraw my consent at any time, and, should I wish to do so, I will contact the clinic to inform them of this intention. I agree that my dental clinic or dental care herein, can collect, use and disclose personal information for the purposes set out herein.

Your Signature

Erin Dental Care

Our Contacts

Email us: smile@erindental.ca
Tel: (519) 833-0563
Address: 9565 Wellington Rd. 124 Erin, N0B 1T0, Ontario, Canada

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Clinic Hours

Monday 9:00am - 5:00pm
Tuesday 9:00am - 7:00pm
Wednesday 9:00am - 7:00pm
Thursday 9:00am - 5:00pm
Friday 9:00am - 4:00pm
Saturday 9:00 - 3:00pm
Sunday: Closed

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