New Patient Form

Welcome to Our Office. Your overall health is important to us. We strive to treat all patients in a safe and effective manner and need to ask some detailed questions related to your general health.

Our office understands the importance of protecting your personal information. To help you understand how we are doing that we have outlined how our office is using disclosing personal information.

This office will collect, use and disclose your personal information for the following purposes:

1. To establish and maintain communication with you
2. To offer and provide treatment, care and service in relation to the oral and maxillofacial complex and dental care generally
3. To communicate with other treating health-care providers, including a specialist general dentist who are the refereeing dentists and or peripheral dentists
4. To allow us to maintain communication and contact with you to distribute the care information and to book and confirm appointments
5. To allow us to efficiently follow up for treatment, care and billing
6. For teaching and demonstrating purpose on an anonymous basis
7. To complete and submit dental claims for third party adjudication and payments
8. To comply with legal and regulatory requirements, including the delivery of patient charts and records to the Royal College of Dental Surgeons of Ontario (RCDSO) in a timely fashion, when required, according to the provisions of the Regulated Health Professional Act (RHPA)
9. To comply with agreement/undertakings entered voluntarily by the members with RCDSO, including delivery and/or review of patient charts and records to the RCDSO in a timely fashion for regulatory and monitoring purposes.
10. To permit potential purchases, practice brokers or advisors to evaluate the dental practice
11. To process credit card payments
12. To collect unpaid accounts
13. To assist this office to comply with all regulatory requirements
14. To comply generally with the law

By Signing the below consent form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purpose that are listed. If a new purpose arises for the use and/or disclosure of your personal information we will seek your approval in advance.

I have reviewed the above-mentioned information that explains how your office will use my personal information, and the steps your office is taking to protect my information

I acknowledged that your office has a copy of the privacy act and I can see it at any time

I agree that Dr. Irina Smirnova can collect, use and disclose personal information about me and described on our collection, use and disclosure of the patient’s personal information policy and the patient consent form.