Your appointment has been reserved exclusively for you to see the dentist, dental hygenist or assistant. Our clinic only sees one patient at a time to maintain the highest quality of patient care. If you need to reschedule your appointment, we require 2 business days' notice or a $150 fee may be applied.

General Release and Consent

I, the undersigned, certify that I have provided an accurate and complete personal, medical and dental history, and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical and dental history. Should there be any change in either my health status or any other information I have provided, I will advise this dental office. I authorize the dentist to perform all diagnostic procedures including and not limited to x-rays and photographs, as may be required to determine necessary treatment, and to perform necessary or advisable treatment. I understand that information provided from or to my medical doctor or another healthcare provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within the guidelines of the policy. I understand that my dental insurance may not cover entirely the total fee of services provided. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.

Consent For Release Of Patient Information

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

We collect information from our patients such as names, home address, work addresses, home/cellular telephone numbers, work telephone numbers and email addresses. Please be aware that if you are providing a work email address for your patient file, your private health information may be accessible to your employer. (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 collect unpaid accounts.

• To process claims for payment or reimbursement from third party health parties or insurance companies.

• To send reminders to patients concerning the need for further examination or treatment.

• To send patients informational material about our office, dental materials or services offered.

• To follow up with treatment and/or customer service.

Consent For Release Of Photos

I also give permission for the doctor to use my photos taken, with my identity removed, for the following purposes:

• Lecturing

• Education

• Marketing

How We Collect And Disclose Your Patient Information

Contact information is disclosed to insurance companies, third party health benefit providers where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment and has authorized us to submit a claim on their behalf. Financial information may be collected to make arrangements for the payment of dental services.

We collect information from our patients 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 for the following purposes:

• 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 the patient has asked us to submit a claim on their behalf.

• To other dentists and dental specialists, where seeking a second opinion and the patient has consented to seek a 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 the other dentists and dental specialists where those dentists have asked us, with the consent of the patient to provide a second opinion.

• To the other health care professionals such as physicians if the patient, with their consent, has been referred to us by the other health care professional for either a second opinion or treatment.

• Dentists are regulated by the Alberta Dental Association and College, which may inspect our records and interview our staff as part of regulatory activities in the public interest.

• I consent to the collection, disclosure and use of my personal information as set out above.