A parent or guardian will be responsible for decisions on my treatment
Medical History (This Information Will Remain Confidential)
List medications or drugs you are taking at this time.
Do you bruise easily or have prolonged bleeding?
Have you ever fainted, or had shortness of breath or chest pain?
For children, Have you recently (within 2-3 weeks) had any of the following (approximate date)?
Have you ever had local anesthetic (freezing)?
I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment and give permission for the collection of this personal information. I will inform the dental office of any updated information regarding my health or other personal information in the future. I certify that all of the information I have completed is correct and that I have not knowingly omitted data. I authorize this dental office to perform diagnostic procedures as may be required to determine the necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependents. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures. I also give permission for this dental office to maintain communication with me via phone or mail for follow-up appointments and billing, the booking and confirmation of appointments and the distribution of dental health information. This dental office may communicate with other treating dentists and healthcare providers including physicians, specialists and/or referring dentists. I give permission for dental claims to be submitted to insurance companies for review and payment under my insurance plans and also to process payments for dental care and other purchases made at this office.
I have reviewed the Privacy Consent Form provided that outlines how the office will use my personal information and the steps the office is taking to protect my information. I agree that Grant Dental Centre can collect, use and disclose personal information as set out in the office's privacy policies.
Patient Privacy Consent Form
For Collection, Use and Disclosure of Personal Information
Privacy of your personal information is an important aspect of our office in providing you with quality 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. Staff are trained in the appropriate uses and protection of your information.
Do not hesitate to discuss our policies with one or any member of our office staff.
Please be assured that every employee in our office is committed to confidentiality and ensuring you receive the best quality care.
How Our Office Collects, Uses and Discloses Patients' Personal Information
Our office understands the importance of protecting your personal information. Outlined below is how our office will collect, use and discloses your information.
By signing the consent section of the 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 PIPEDA and for the defence of a legal issue.
Our office will not under any conditions supply your insurer with your confidential medical history. In the event this type of request is made, we will forward the information directly to you for your 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.
You may withdraw your consent for the use or disclosure of your personal information, and we will explain the ramifications of that decision and the process.