Personal Information

Consent Form

Personal Information Consent Form

Personal Information 

Personal information for our purposes is; that information necessary for the provision of professional oral health care services provided to you, and information necessary to administer this dental practice.  Personal information includes all that information provided by you to us on our patient information/health/medical history form at the first visit and any subsequent visits.  Personal information may also include any information provided by you to us during the normal course of communication between patient and dental office staff.  We will use and disclose only the information provided to us by you or another person acting on your behalf.

Information Protection

We are committed to protecting your personal information.  We have established and implemented a variety of security measures. These include, but are not limited to the use of video cameras, to properly manage and safeguard your personal information from loss, theft and unauthorized access.

Information Disclosure

Your personal information shall be disclosed to only those who have a need to know and the specific information disclosed shall be restricted to only that information relevant to the recipients need to know.  Those who have a need to know include, but are not limited to, other dentists, health care providers, dental specialists, personal physicians, dental laboratories, radiology centres.   Your financial information will be disclosed to whoever has been written as financially responsible for the account.  Further, the personal information disclosed to dental benefit providers is limited to only that personal information required by the provider.

If we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted access to patient information in order to verify information important to the potential sale.  If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information.  (Dentists are regulated by the Alberta Dental Association and College which may inspect our records and interview our staff as part of its regulatory activities in the public interest.)

Information Destruction

We will destroy information in a secure manner when the information is no longer necessary for the provision of oral health services and is not required to be retained for compliance with provincial or federal regulations or statutes.

Financial Information Consent

We require you to leave your credit card on file to direct bill your insurance company.  Once your insurance company has paid us their portion, our team members will process your patient portion to the credit card on file. As long as we have your insurance details we will submit to your insurance and ask that you pay the amount not covered at each visit.  If we do not have your insurance details you will be required to pay at your visit and get reimbursed from your insurance company.

Cancellation Policy

We understand that situations arise in which you must cancel your appointment. It is, therefore, requested that if you must cancel your appointment you provide 2 FULL  DAYS notice.  This will enable another patient who is waiting for an appointment to be scheduled in that appointment slot.

No show appointments and/or appointments that are cancelled with less than 48 hours notice may be subject to a min  $50 cancellation fee.


Having read and understood the Privacy Statement for patients, I consent to the collection, use and disclosure of my personal information as presented in the statement

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