Quad Dental

95 The Pond Road, Unit 60

Toronto, Ontario M3J0L1

PERMISSION TO COLLECT, USE AND DISCLOSE PERSONAL INFORMATION

Our office understands the importance of protecting your personal information.

We will collect, use and disclose your personal information only for appropriate purposes:

  1. To diagnose and provide health care.
  2. To communicate with you and your other health care professionals.
  3. For scheduling and billing purposes, including completion of dental claim forms
  4. To comply with the legal requirements of the RCDS of Ontario, provincial regulations, and to generally comply with the law.
  5. For audit and evaluation of the dental practice.
  6. To provide and invoice, process credit or debit card payments, and to collect unpaid accounts.
  7. If at any time the practice were to transfer ownership for the purpose of uninterrupted care, to transfer your full patient information file.

If a new purpose would arise for the use and disclosure of your personal information, we will seek your approval in advance. We will not under any conditions supply your insurer with your confidential medical history, without your specific consent. If unusual requests are received, we will contact you for permission prior to releasing such information. You many withdraw your consent for use of disclosure of your personal information, and we will explain the ramifications of that decision. In this office, any Doctor may act as the Privacy Information Officer. Do not hesitate to discuss our policies with any member of our office staff.

Patient Consent

I have reviewed the above information that explains how our office will use mypersonal information, and the steps taken 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 Quad Dental can collect, use and disclose personal information about me as set in the above privacy policies.
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