My Child's Information
My Child's Dental History
My child's Medical History
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If there is ever any change in my child's health, I will inform the doctor(s) at the next appointment.
Consent For TreatmentPlease read and acknowledge by checking the boxes below:
Our Practice respects your confidentiatlity and privacy.
When you receive health services from our Practice, we will collect individually identifying health information in accordance with the provisions of the Health Information Act.
We will collect this health information directly from you, except in the limited circumstances where we are authorized under HIA (section 20 (b)) to indirectly collect such information.
We are committed to protecting the privacy of our patients’ personal information and to utilizing personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances in this form, we also collect, use and disclose personal information when permitted or required by law.
We collect information from our patients such as names, home addresses, mobile telephone number, home telephone number, work telephone numbers and e-mail addresses. (Collectively referred to as “Contact Information”)
Contact Information is collected and used for the following purposes:
Contact Information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment and has asked us to submit a claim on their behalf.
Financial information may be collected in order to make arrangements for the payment of dental services.
We collect information from our patients about their health history, their family health history, physical condition and dental treatments. (Collectively referred to as “Medical Information”). Patients’ Medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment.
Patients’ Medical Information is disclosed for the following purposes:
If we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted access, as part of the due diligence process, 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.
I consent to the collection, use and disclosure of my personal information as set out above.
I have read all of the above statements and accept the terms and conditions as stated.