Willowdale Dental Group - Yonge & Sheppard    Back to Forms

Privacy Consent Form

FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

25 Sheppard Ave. W., #125, North York, ON, M2N 6S6      416-226-2535

Patient's Name:
E-mail:

We understand the importance of protecting your personal information and are committed to collecting, using and disclosing it responsibly. All our staff members are aware of the sensitive nature of information you disclose to us and are trained in the appropriate uses and protection of your privacy. Willowdale Dental Group - Yonge & Sheppard acts as Privacy Information Officer

In this consent form we outline what we are 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 privacy legislation and standards of our regulatory body, The Royal College of Dental Surgeons of Ontario

We have outlined below how our office is using and disclosing your information:

  1. to deliver safe, efficient and high quality patient care
  2. to asses your health needs and advise you of treatment options
  3. to contact you to book/confirm appointments and to allow us to follow-up on treatment and billing
  4. to remind you of your appointments via text/sms, email or phone call with our automated system, Recall System Pro
  5. to sent promotions and marketing newsletters via email and sms
  6. to provide treatment options, care and services in relationship to oral and maxillofacial health and dental care in general
  7. to communicate with healthcare providers; specialists or general dentists who are referring or peripheral clinicians
  8. to complete and submit dental claims for third party adjudication
  9. to comply with legal 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
  10. to permit potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale
  11. to deliver records to dentist’s insurance carrier to enable insurance company to assess liability and quantify damages, if any to prepare materials for the Health Professions Appeal and Review Board (HPARB)
  12. to invoice for goods and services, to collect unpaid accounts and process credit card payments
  13. to assist this office to comply with all regulatory requirements and comply generally with the law
  14. for teaching and demonstrating purposes on an anonymous basis

By signing the Patient Consent Form, you agree to giving your informed consent to the collection, use and/or disclosure of your personal information for the purposes 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 (RI-IPA) for the purpose of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for the defense of a legal issue. Our office will not under any conditions supply your insurer with your confidential medical history. In the event this kind of a request is made, we will forward the information directly to you for review, and for your specific consent. 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.

Should you choose to refuse to give consent for use/disclosure of your personal information, we will explain the ramifications of that decision to you.

Patient Consent

Signature