Responsible Party who completed this form- Please sign

Office Policy for the Collection, Use and Disclosure of Patient Personal Information

As dental professionals, we are required to comply with Federal and Provincial Privacy Legislation (PIPEDA) and (PHIPA). In order to do so, each of our patients must sign a consent form acknowledging and allowing us to collect, use and disclose personal information according to specific guidelines.

Privacy of your personal information is an important part of our commitment to providing you with quality orthodontic care. We understand the importance of protecting your privacy, and we are committed to collecting, using and disclosing your personal information responsibly.

All team members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information.

Our office has a Privacy Code, which you may review at any time, and freely discuss with our Privacy Information Officer (federal) also known as our Health Information Custodian (provincial).

Attached to this consent form, we have outlined what our office is doing to ensure that:

  • Only necessary information is collected about you;
  • We only share your information with your consent;
  • Storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols;
  • Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law.

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

This office will collect, use and disclose information about you for the following purposes:

  • to assess your health needs and risks, advise you of treatment options and deliver safe and efficient orthodontic care.
  • to enable us to contact you to: distribute health-care information, book and confirm appointments, efficiently follow-up for treatment
  • to communicate with other treating health-care providers, including other specialists and general dentists, and/or referring dentists, physicians, pharmacists, and laboratory technicians
  • to allow us to efficiently manage your account, including billing, obtaining debit and credit card payments, and for collection of unpaid accounts]
  • to complete and prepare orthodontic treatment estimates / claims for third party adjudication and payment
  • to comply with legal and regulatory requirements, including the delivery of patients' charts and records to the Royal College of Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of the Regulated Health Professions Act
  • to permit potential purchasers, practice brokers or legal and financial advisors to evaluate the orthodontic practice and / or conduct an audit in preparation for a practice sale
  • to deliver your charts and records to the orthodontist's insurance carrier to enable the insurance company to assess liability
  • for teaching and demonstrating purposes on an anonymous basis
  • to assist this office to comply with all regulatory requirements and comply generally with the law
Patient Acknowledgement and Consent

I have reviewed the above information that explains why and how your office will collect, use and disclose my/my child's personal information, and the steps your office is taking to protect my information.

I know that your office has a Privacy Code, and I can ask to see the Code at any time.

(Patient Name)


Witness Signature:

Image Consent Form

The purpose of this form is to grant permission to Dr. Shakti Singh/Dr. Allyson Bourke , and / or her team to display pictures of the below named patient within our waiting room or in our educational material, brochures, website, and or our social media, at any time during or following his / her orthodontic treatment. For example, contest winners, debond collage.

This form must be completed and signed by either:

  1. The patient, where he or she is over 18 years old, OR
  2. A responsible party of the patient, where the patient is under 18 years old.
(Patient or Responsible Party's Name - PLEASE PRINT)
(Patient's Name - PLEASE PRINT)

(Signature of Patient or Responsible Party)