Personal Information Consent Form

We are committed to protecting the privacy of our patient’s personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances described 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 address, telephone numbers, and e-mail address (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, process credit card payments, arrange for payments of our services, and collect unpaid accounts.
• To process claims for payment from third party insurance and benefits providers.
• To send reminders to patients concerning the need for further dental examinations and or treatment.
• To send patients informational material about our dental practice.

We collect information from our patients about their health history, family health history, physical conditions, and dental treatments (collectively referred to as ‘Medical Information’). Patient’s Medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment.

Contacted information and medical information may be disclosed to third party health benefit providers and insurance companies. Medical information is collected and used for the following purposes:

• To other dentists and dental specialists where we are seeking a second opinion and the patient has consented to us to obtain a second opinion.
• To other health professionals such as physicians, if the patient has consented and has been referred to us by other health care professionals for either a second opinion or treatment.

If we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted access as part of the due diligence process 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 safeguards all personal information.

Dentists are regulated by the Alberta Dental Association and College which maybe inspect our records and interview our staff as part of its regulatory activities in the public interests.

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

This information is collected under the authority of the Freedom of Information + Protection of Privacy Act Section 33(c). If you have any questions about collection of your personal information please contact our Office Manager or Dr. Kyle Reddick directly at (403) 255-3202.