APPLICATION FORM

THIS NOTICE DESCRIBES HOW PERSONAL HEALTH INFORMATION ABOUT THE APPLICANT MAY BE COLLECTED, USED, DISCLOSED AND ACCESSED. PLEASE REVIEW IT CAREFULLY.

Uses and Disclosures

Treatment: Your personal health information may be used by our orthodontic team and staff, including, but not limited to for the purpose to evaluate your eligibilty for the Give Back a Smile Program, plan and provide orthodontic care and communicate with the applicant's dentist or other health-care providers as needed.

Program Administration: We may use applicant information such as name, dental/medical history and photographs for applicant assessement, care coordination and internal review.

Legal Requirements: We may disclose personal health information when required by law. For example, information may be shared to comply with court orders, investigations or other legally mandated reporting.

Public Health: If required by law, personal health information may be shared with public health authorities. For example, we are required to report communicable diseases to the health department.

Other Uses Requiring Permission: Any use or disclosure of personal health information not listed in this notice will require written consent. Applicants can withdraw consent at any time by submitting written notice. Withdrawal will not affect information already in use or disclosed before the withdrawal was received.

Individual Rights: You have certain rights under federal privacy standards. These include the right to request access to the applicant's personal health information. The right to request corrections to personal health information. The right to ask how your personal information has been shared. The right to request restrictions on use or disclosure. The right to receive a printed copy of this notice. Requests must be submitted in writing.

Program Responsibilities: We are required by law to protect your personal health information and will provide applicants with updates about our privacy practices if changes occur. We are required by law to contact you if a privacy breach involving personal health information has occurred.

Right to Revise Privacy Practices: As permitted by law, we may revise this notice from time to time to reflect changes in law or our information practices. The updated notice will apply to all personal health information we maintain and will be made available upon request.

Access to Records: You may request access to personal health information we hold. The request must be submitted in writing. We will provide instructions on how to request a copy or make corrections.

Questions, Concerns or Complaints: If you have questions or concerns about our privacy practices, or if you would like to submit a complaint regarding our privacy practices, you may contact us in writing at the following address: 5353 Dundas St W, Suite 201, Toronto ON, M9B 6H8, or complaints may also be directed to the Information and Privacy Commissioner of Ontario. You will not be penalized for filing a complaint.

Effective Date: This notice is effective as of November 11th 2025. By signing below, the parent/guardian confirms they have received a copy of this Notice of Privacy Practices for this Program.

 

Rules and Regulations

Dr. Monica Gawlik is excited to offer this special opportunity for one child to receive free orthodontic treatment. However, we will only provide treatment if the applicant fully cooperates with the treatment provider and his/her treatment plan. All of the following conditions must be met to be eligible in order to start and continue treatment. 

PARENT/GUARDIAN, PLEASE READ CAREFULLY AND INITIAL EACH ITEM.

 

1. Six Points Orthodontics and Mississauga Orthodontics will provide orthodontic treatment ONLY. Any dental procedures needed before, during, or after orthodontic care, such as routine cleanings, extractions, fillings or other necessary treatment, are the financial responsibility of the patient/family.

2. To qualify, the applicant must have good oral hygiene and no untreated cavities or periodontal concerns. Any necessary dental work must be completed before orthodontic treatment begins. Regular dental clanings every six months or sooner during orthodontic treatment are required. If oral hygiene is not maintained and cavities or other concerns develop, the applicant may be removed from the program.

3. Regular appointments are required to ensure proper tooth movement. Because treatment is provided at no cost, some appointments may be scheduled during non-peak hours (during mid-morning or mid-afternoon hours). Families are responsible for attending all scheduled visits. If you need to cancel or reschedule your appointment, at least 24 hours notice is required. Failure to show up or call may result in removal from the program and discontinuation of treatment.

4. The applicant must follow the treatment plan provided by the orthodontist. This includes, but is not limited to proper use and care of braces, aligners, elastics, appliances, retainers and other instructions. Failure to follow instructions may result in removal from the program and/or removal of braces or appliances. 

5. If the applicant moves away before treatment is complete, Six Points Orthodontics or Mississauga Orthodontics must be informed. At that time the patient will be removed from the program and the family will be responsible for arranging and paying for continued care with another provider. Six Points Orthodontics or Mississauga Orthodontics is not responsible for finding a new clinic or covering further treatment costs.

6. The applicant may be removed from the program at any time (this includes during the application process, before and after treatment has started) if they fail to follow program rules, are uncooperative, or behave disrespectfully towards staff. If an applicant is removed for misconduct, Six Points Orthodontics or Mississauga Orthodontics may discontinue treatment and remove orthodontic appliances. If an applicant is dismissed for cause, they will not be eligible to reapply to the program.

7. Broken or loose orthodontic appliances can cause complications to teeth and the rest of the mouth. The applicant must avoid hard, sticky or chewy foods and refrain from pulling or tampering with braces. If braces or appliances are frequently damaged, Six Points Orthodontics or Mississauga Orthodontics may discontinue treatment and remove appliances or charge the family for repair costs.

8. One (1) retainer will be provided at no cost once treatment is completed. If the retainer is lost or damaged, the applicant is responsible for replacement fees.

Consent and Hold Harmless Agreement

By signing below, I confirm that I have read, understand and agree to follow the Program Rules and Guidelines for receiving orthodontic treatment through the Give Back a Smile Program at Six Points Orthodontics or Mississauga Orthodontics. I have been given the opportunity to ask questions about the program.

If the applicant is accepted into the program, I give permission for Six Points Orthodontics or Mississauga Orthodontics to provide orthodontic care to the applicant. I understand that participation in this program requires the applicant to maintain good oral hygiene and comply with all Program Rules and Guidelines. If these expectations are not met, Six Points Orthodontics or Mississauga Orthodontics may discontinue treatment and remove orthodontic appliances.

I understand that if treatment must stop for any reason—including failure to follow the Program Rules and Guidelines—Six Points Orthodontics or Mississauga Orthodontics will not be responsible for injury, damage or future treatment needs that may result from ending care. I agree not to hold Six Points Orthodontics and/or Mississauga Orthodontics or its team responsible for any related costs or claims.

I authorize Six Points Orthodontics or Mississauga Orthodontics and the applicant’s family dentist (as listed in the application) to share dental and medical information as needed to coordinate treatment and ongoing care.

In exchange for participation in the program, I release Six Points Orthodontics or Mississauga Orthodontics, partner dentists, owners, staff, and representatives from any liability or claims that may arise from the applicant’s participation in the program, including but not limited to program dismissal or removal of orthodontic appliances.

I understand that while treatment will be provided to the best of the team’s ability, treatment outcomes cannot be guaranteed.

I agree to receive communication about the program and treatment by email and will ensure a current email address is on file. I understand it is my responsibility to notify the clinic if my contact information changes.

If any part of this agreement is found invalid, the remaining terms will still apply.

Parent/Guardian Consent: I certify that all information provided in this application is accurate. I understand that providing false or misleading information may result in the applicant being removed from the program.