Personal Information Consent Form

We are committed to protecting the privacy of our patients' personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information when required by Jaw.

We collect information from our patients such as their names, addresses (home, work), telephone numbers (home, cell, work) and email addresses; their health history, physical condition, and dental treatment history. Contact and Medical Information is collected and used in diagnosing dental conditions and providing dental treatment for the following purposes:
- To open and update patient files.
- To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts, possibly from a third party agency.
- To process claims for payment or reimbursement from insurance companies.
- To send reminders to patients concerning the need for further dental examination or treatment.
- To send patients informational material about our dental practice.
- To communicate with insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient's behalf.
- To communicate and coordinate treatment plans with other dentists and dental specialists.
- When the patient has consented to have us obtain a second opinion
- When the patient has consented to have the other dentist or dental specialist obtain a second opinion from us.
- When the patient has been referred by us to the other dentist or dental specialist for treatment.
- When the patient has been referred to us by the other dentist or dental specialist for treatment.
- To communicate, with the consent of the patient, with other healthcare professionals who have referred the patient to us for either a second opinion or treatment.
We do not disclose any personal information and email addresses to any other agencies.

Contact Information is disclosed to insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient's behalf. Financial information may be collected in order to make arrangements for the payment of dental services.

Dentists are regulated by the Alberta Dental Association and College, which may inspect our records and interview our staff as part of its regulatory activities in the public interest.
*
- I consent to the collection, use and disclosure of my personal information as set out above.
I would like to receive the White Oak Dental newsletter and other important office updates.*
- Yes
- No
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