Please fill out this form in conjunction with both the Medical History and Dental Questionnaire forms on our website. Patient Consent Form: For Collection, Use and Disclosure of Personal Information I acknowledge the privacy of my personal information is an important part of this office providing quality dental care. Rose Dental understands the importance of protecting your personal information. They are committed to collecting, using and disclosing my personal information responsibly. They also try to be as open and transparent as possible about the way they handle my personal information. It is important tothe office that they provide this service to their patients. All staff members at Rose Dental who come into contact with my personal information are aware of the sensitive nature of the information that I have disclosed to them. They are all trained in the appropriate uses and protection of my information. * Yes, I acknowledge this No I acknowledge that Rose Dental has outlined what they are doing to ensure that: only necessary information about me is collected, they only share my information with my consent, storage, retention and destruction of my personal information complies with existing legislation and privacy protection protocols. Their privacy protection complies with privacy legislation, standards of their regulatory body, and the College of Dental Hygienists of Ontario and/or the Royal College of Dental Surgeons of Ontario, and the law. * Yes, I acknowledge this No I am aware that every staff member at Rose Dental is committed to ensuring that I receive the best quality care, and I will not hesitate to discuss their policies with them. * Yes, I acknowledge this No I acknowledge that Rose Dental will collect, use and disclose information about me for the following purposes: to deliver safe and efficient patient care, to identify and ensure continuous high quality service, to assess my health needs and provide health care, to advise me of treatment options, to enable the office to contact me and maintain communication with me (including distributing health care information and to book and confirm appointments), to offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care generally, to communicate with other treating health care providers including physicians, pharmacists, referring general dentists and specialists, to allow the office to efficiently follow-up for treatment, care and billing, for teaching and demonstration on an anonymous basis, to complete and submit dental claims for third party adjudication and payment, to comply with legal and regulatory requirements including the delivery of patients charts and records to the Royal College of Dental Surgeons of Ontario and/or the College of Dental Hygienists of Ontario in a timely fashion when required according to the provisions of the Regulated Health Professionals Act, to comply with agreements/undertakings entered into voluntarily by Rose Dental and staff with the Royal College of Dental Surgeons of Ontario and/or the College of Dental Hygienists of Ontario, including the delivery and/or review of patient's chart and records to the college(s) in a timely fashion for regulatory and monitoring purposes, to permit purchasers, practice brokers or advisors to evaluate the practice and potentially allow such people to conduct an audit in preparation for a practice sale, to deliver my charts and records to the staff's insurance carriers to enable the insurance company to assess liability and quantity damages if any, to prepare materials for the Health Professions Appeal and Review Board (HPARB), to invoice for goods and services, to process credit card payments, to collect unpaid accounts, to assist this office to comply with all regulatory requirements, to comply generally with the law. * Yes, I acknowledge this No I acknowledge that by reading the consent sections of this Patient Consent Form, I have agreed that I have given my informed consent to the collection, use and/or disclosure of my personal information for the purposes that are listed. If a new purpose arises for the collection, use and/or disclosure of my personal information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of my personal information, Rose Dental will seek my verbal and/or written approval in advance. My information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario and/or the College of Dental Hygienists of Ontario fulfilling its mandate under the RHPA, and for the defense of a legal issue. Rose Dental will not supply my insurance company with my confidential medical history information. If such a request is made, they will obtain specific request from me to forward such information along. When unusual requests are received, Rose Dental will contact me for permission to release such information. Rose Dental may also advise me if such a release is inappropriate. I may withdraw my consent for use and disclosure of my personal information and Rose Dental will explain the ramifications of that decision and the process. * Yes, I acknowledge this No Consenting Signature * I have reviewed the above information that explains how Rose Dental will use my personal information, and the steps this practice is taking to protect my information. I know that your practice has a Privacy Code, and I can ask to see the Code at any time. I agree that Rose Dental can collect, use and disclose personal information about myself and/or family as set out above in the information about the office's privacy policies. First Name Last Name Date * MM DD YYYY Thank you!
