Privacy and Personal Information Form

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    Patient Name (Full name) *

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    Parent/Legal Guardian (Full name) *

Our office understands the importance of protecting your personal information By choosing 'Yes' I give consent to Downtown Sleep Dentistry & Oral Surgery to collect, use and disclose information for the following purposes:
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To enable us to contact you (your child) and to book and confirm appointments.
YesNo

To advise you of treatment options
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To communicate with other health-care providers, including medical/pharmacy and dental specialists and general practitioners
YesNo

To comply with legal and regulatory requirements, including the delivery of patients' charts and records of the Royal College of Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of the Regulatory Health Professions Act.
YesNo

To comply with agreements/undertakings entered into voluntarily by Downtown Sleep Dentistry & Oral Surgery with the Royal College of Dental Surgeons of Ontario, including the delivery and/or review of patients' charts and records of the College in a timely fashion for regulatory and monitoring purposes.
YesNo

To prepare material for the Health Professions Appeal and Review Board
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To comply with Bill C-28 and Legislation of the Federal Government surrounding Commercial Electronic Communication via electronic address, telephone and similar accounts for transmission of patient and/or appointment related material.
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To process credit card payments
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To collect unpaid accounts
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You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision, and the process.
By clicking "yes" on this consent form, you have agreed that you have given your informed consent to collection, use and/or disclosure of your personal information for the purposes listed
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