Medical & Dental History Form

At the DOC+, we are committed to providing quality care to our patients. We have established the following policies and procedures so that each patient may receive consistent expert service:

✔ All appointments must be made in advance by phone or online booking system.

✔ For all oral or periodontal surgery procedures, a deposit of 10% of the total cost is required prior to the scheduled appointment date in order to secure treatment. The remainder of the balance will be processed after the procedure. All deposits are non-refundable.

✔  All patients must arrive at least 10 minutes prior to their appointment time or the appointment will be cancelled and a new appointment must be scheduled.

✔  We kindly request that all cancellations be done 48 hours prior, or a cancellation fee may apply. As long as the cancellation policy is followed, a full refund will be granted including your initial deposit.

✔  If there is a “No Show” or the appointment is cancelled without proper and advanced notice, a fee of 10% of your services will apply. When a patient fails to cancel appropriately, it prevents other patients the opportunity to receive treatment sooner.

✔  Payment is due at the time of service unless other financial arrangements have been made in advance with our office manager/billing specialist. 

✔  Your insurance policy is a private contract between you and your insurance company; we cannot be responsible if there is a change, decline or delay in your benefit. We will help you understand your insurance and provide you with the appropriate documents you may need.

✔  For your safety, it is essential that you inform us of any medical conditions or allergies that could affect your treatment plan or care during your visit.

✔  Respectful language, attitude and behaviour towards staff members is expected at all times in order for us to provide excellent customer service to you, our valued patient.

FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION:

 

Privacy of your personal information is an important part of DOC + providing you with quality dental care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is important to us to provide this service to our patients.

 

All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information.

 

 In this consent form, we have outlined what our office is doing to ensure that:

 

∙ only necessary information is collected about you;

∙ we only share your information with your consent;

∙ storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols;

∙ Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law.

 

Do not hesitate to discuss our policies with us or any member of our office staff. Please be assured that every staff person in our office is committed to ensuring that you receive the best quality dental care.

 

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

✔ to provide health care

✔ to advise you of treatment options

✔ to enable us to contact you

✔ 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 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 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 prepare materials for the Health Professions Appeal and Review Board (HPARB)

✔ to invoice for goods and services

✔ to process credit card payments

✔ to collect unpaid accounts by the office

✔ 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 defence of a legal issue. 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.