Consent Form & Policy

PIPEDA CONSENT FORM - How Our Office Collects, Uses and Discloses Patients' Personal 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. This 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 service to assess your health needs and 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 physicians, 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 patients’ 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 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 patients’ 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 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 Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for 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 a request is made, we will forward the information directly to you for review, and for your specific consent. When unusual requests are received, we will contact you for permission to release such information. We may also advise you if such a release is inappropriate. You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision, and the process. Patient Consent: 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.I agree that Dr. Simi Silver Dentistry Professional Corporation can collect, use and disclose personal information about (name of minor child if necessary) as set out above in the information about the office’s privacy policies

510 RICHARDSON AVE OTTAWA, ON K2B 5H1 613-829-5921 www.silverdentalcentre.com
I have reviewed the attached information that explains how Silver Dental Centre will use my personal information, and the steps the office is taking to protect my information.

I know that Silver Dental Centre has a Privacy Policy Code, and I can ask to see the code at any time.

I agree that Dr. Simi Silver can collect, use, and disclose my personal information about my treatments as set out above in the information about the office’s privacy policy.

I have also reviewed the Silver Dental Centre’s (Management of Percutaneous Injuries) Office Protocol. I have had an opportunity to read this Protocol and ask questions. My questions have been answered to my Satisfaction.

I give my consent to be contacted by text or email.
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Witness Signature

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Office Policy:
Your dental appointment time is reserved especially for you. We require 48 hour notice if you are

unable to keep a reserved appointment, otherwise it may be necessary to charge for time lost if insufficient notice is received. The fee will be determined by the dentist or hygienist you have been scheduled with. We understand and respect that your time is valuable as well, and will endeavor to see you at your reserved time.

Patient Release: I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary. I also understand that consultation with my medical doctor may be required, and I consent to my physician being contacted as necessary. I understand that responsibility for payment for the dental services for myself and my dependants is mine, and I will assume responsibility for fees associated with these services.

Insurance Policy: I understand that the fees listed for dental treatment may not be covered by or may exceed my dental benefits. I understand that I am financially responsible to my dentist for the entire cost of treatment. I authorize the release of information regarding dental treatment to my Insuring Company/ Plan Administrator via manual claim forms and/ or electronic transmission. I authorise communication of and submission of information related to the coverage of services provided to the named dentist.

Payment is required at time of treatment. Payments may be made by VISA, MasterCard, Debit or Cash. Special financial arrangements may be made for major treatment costs. Speak with the office before treatment begins.
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Signature of Reviewing Dentist:

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MANAGEMENT OF PERCUTANEOUS INJURIES

In all cases of significant exposure, the dentist will assess the source patient's status and risk for blood-borne illness by reviewing the medical history and, if necessary asking the patoent additional questions.

In the case where the patient may have an exposure to blood/ body fluid, the dentist will inform the patient of the incident and their risks. The patient would follow the same Office Protocol.

If the source patient's status is unknown or the patient present with known risk factors, then their cooperation should be sought to clarify information and/or provide consent to be tested. Given that a decision regarding the source patient's status is best made quickly referring the patient to a hospital emergency department may be prudent.

The injured person should be given the option to attend a medical consultation with the nearest hospital emergency department for counselling, possible baseline bloodtests and consideration for post-exposure prophylaxis (PEP). When necessary, PEP should be administered as soon as possible (within one hour). PEP against HIV reduces risk of transmission by 75% when given within an hour of exposure.

The exposed person should have follow up examinations after two weeks, one, three and six months. Trained clinicians should give counselling about the need to avoid transmission to sexual partners.

HOSPITAL INSTRUCTION:

ONTARIO RESIDENTS: The exposed person must proceed to the closest Emergency Department (Civic Hospital Infectious Disease Department- phone # 613-737-7777). Upon arrival at the hospital, inform the administration that you require that you require immediate treatment. A staff member will call the Infectious Disease Department to inform them that the exposed person is proceeding to the hospital for immediate treatment. There is a two-hour window from the time of the percutaneous or mucosal exposure to be treated.

QUEBEC RESIDENTS : Must proceed to the Gatineau Hospital (as per the Quebec Health Care Guidelines). A staff member will call the Infectious Disease Department to inform them that the exposed person is proceeding to the hospital for immediate treatment. Upon arrival at the hospital, inform the administration that you require immediate treatment. There is a two-hour window from the time of the percutaneous or mucosal exposure to be treated.
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