Patient Consent form

We are happy to provide immediate emergency treatment to our patients in need at Harmony Dental Care. Walk-ins and new patients are always welcome!

All our 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.

They are all trained in the appropriate uses and protection of your information. Our office will ensure that only the necessary up to date information is collected about you, that we only share this information with your consent, that the storage, retention and destruction of your personal information complies with existing legislation and that our office privacy protocols comply with the privacy legislation.

This office will collect, use and disclose information about you for the following purposes:

• ❖ to assess the health needs and provide health care to you and your family.
• ❖ to advise you and/or your family members of treatment options
• ❖ to enable us to contact you or your family members for treatment appointments, billing and payment
• ❖ to communicate with other health care providers, including specialists and general dentists, physicians and pharmacists
• ❖ to complete and submit dental claims for third party authorization and payment
• ❖ to comply with all legal and regulatory requirements

Provision of this information sheet to you will constitute your informed consent to the collection, use and/or disclosure of your personal information for the above purposes.

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.