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GO Dental – Personal Information Consent Form
At GO Dental we are committed to protecting the privacy of our patients’ personal information and utilizing all personal
information in a responsible and professional manner. This document summarizes some of the personal information 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 law.
We collect information from our patients such as names, home address, work address, home telephone numbers, e-mail
addresses, birthdays and other government, corporate and/or personal data (collectively referred to as “Contact
Information”). Contact Information is collected and used 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.
•
To process claims for payment or reimbursement from third party health benefit providers and insurance
companies.
•
To send reminders and/or phone patients concerning the need for further dental examination or treatment.
•
To send patients informational material about our dental practice.
Contact Information is disclosed to third party health benefit providers and insurance companies where the patient has
submitted a claim on the patient’s behalf.
Financial information may be collected in order to make arrangements for the payment of dental services.
We collect information from our patient’s about their health history, their family health history, physical condition and
dental treatments (collectively referred to as “Medical Information”). Patients’ Medical Information is collected and used for
the purpose of diagnosing dental conditions and providing dental treatment.
Patients’ Medical Information is disclosed:
•
To third party health benefit providers and 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 other dentists and dental specialists where we are seeking a second opinion and the patient has consented to
us obtaining the second opinion.
•
To other dentists and dental specialists if the patient, with their consent, has been referred by us to the other
dentist or dental specialist for treatment.
•
To other dentists and dental specialists where those dentists have asked us, with their consent, has been referred
by us to the other health care professional for either a second opinion or treatment.
•
To other health care professionals such as physicians if the patient, with their consent, has been referred by us to
the other health care professional for either second opinion or treatment.
If we are ever considering selling all or part of our dental practise, as part of the due diligence process, qualified potential
purchasers may be granted access to patient information in order to verify information important to the potential sale. If
this occurs, we will take steps to ensure that the prospective purchaser safeguard all personal information.
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.
____________________________
______________________________
________________________________
Date
Print Name
Signature

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