Patient Consent & Office Policies

I hereby acknowledge responsibility for all fees charged for treatment rendered whether covered by my insurance or not. In addition, I understand that a fee will be charged for missed appointments by myself (or my children) where at least 24 hours notice is not provided.

I also give consent (if necessary) to photographs being taken and used for illustration of my treatment.

I consent to electronic submission of my dental claims to my insurance company.

I also consent to your collection, of any and all personal information about me including personal health information and all personal information about any minor of whom I have joint or sole parental custody, and to use such information in any manner or for any purpose whatsoever, but only in the course, of, concerning, or relating to, your dental practice.

I similarly consent to the disclosure to third parties of all such information but only in accordance with the Regulated Health Professionals, the Dentistry, and Dental Hygiene Acts of Ontario PHIPA (a copy of our privacy policy is available to you in our office) and to any insurer or other payment organization who my be responsible for payment of all or part of any treatment or service you provide.