Your co-operation in completing this questionnaire is essential to providing you with the highest standard of dental care. All information is strictly confidential and will remain with this office. Our receptionist is available to assist you with the completion of this form.
Our office understands the importance of protecting your personal information.
We will collect, use and disclose your personal information only for appropriate purposes:
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.
I have reviewed the above information that explains how our office will use my personal 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.