Privacy statement for patients and consent form

Privacy of our patient's personal information is important to us. We are committed to collecting, using, and disclosing personal information responsibly. Our office has established and implemented a variety of security measures to properly manage and safeguard your personal information from loss, theft and unauthorized access.

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 clinical records, x-rays, study models, photographs of your teeth, mouth, smile, face, and general health information obtained from a medical history review, insurance information, phone numbers and addresses. Clinical information and photographs, x-rays may also be used for long-term follow-up and research purposes, as well as for education or teaching purposes.

Your personal information shall be disclosed to only those who have a need to know and 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 referring dentists, other dental specialists, physician(s), dental laboratories and insurance carriers. Information may be transmitted via email, courier and regular mail.

I certify that I have read and understand this document.