Callingwood Square Shopping Centre
6643-177 Street, Edmonton, Alberta T5T 4K3
Phone: (780) 483-1338 Fax: (780) 483-1393
Email: Website:


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Electronic Insurance Submission:
Primary Insurance
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Secondary Insurance
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Patient Release
Patient Consent Form for Collection, Use and Disclosure of Personal Information
  • 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 and the law.
How Our Office, Uses and Discloses Patients’Personal Information

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

  • to deliver safe and efficient patient care
  • to identify and to ensure continuous high quality service
  • to assess your health needs
  • to provide health care
  • to enable us to contact you
  • to establish and maintain communication with you
  • to communicate with other treating health-care providers, including specialists and general dentists who are the referring dentists and/or peripheral dentists
  • to allow us to efficiently follow-up for invoicing and/or billing
  • for teaching and demonstrating purposes on an anonymous basis to include research and publications
  • to complete and submit dental claims for third party adjudication and payment
  • to process credit or debit card payments
  • to collect unpaid accounts
  • to assist this office comply with all regulatory requirements
  • to comply generally with the law
Patient Consent