new patient form

1Medical History

2Privacy

3Insurance

Country Park Dental
101-1450 Block Line Road, Unit #101 Kitchener, ON N2c 0A5
HOW OUR OFFICE COLLECTS, USES AND DISCLOSES PATIENT’S PERSONAL INFORMATION
Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined below how our office is using and disclosing your 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 and advise you of treatment options
- To enable us to contact you, establish and maintain communication with you
- To offer and provide treatment, care and services in relationship to oral maxillofacial complex and dental care in general
- To communicate with other treating health care providers, including specialists and general dentists who are the referring dentists an/or peripheral dentists
- To allow us to maintain communication and contact with you to distribute health-care information, and to book and confirm appointments
- To allow us to efficiently follow-up for treatment, care and billing.
- To complete and submit dental claims for third party adjudication and payment
- To comply with legal and regulatory requirements, including the delivery of patients’ charts and records in the Royal College for Dental Surgeons of Ontario in a timely fashion, when required according to the provisions of the Regulated Health Professions Act
- To comply with agreements/undertakings entered into voluntarily by the member with the Royal College of Dental Surgeons in a timely fashion for regulatory and monitoring purposes.
- To permit potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale
- To deliver charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability and damages, if any
- To prepare material for the Health Professions Appeal and Review Board (HPARB)
- To invoice for goods and services and process credit card payments
- To collect unpaid accounts
- To assist that this office comply with all regulatory requirements
- To comply generally with the law
By signing the consent of this patient 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 purposes 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. Our office has a Privacy Code and you can ask to see it anytime. After reviewing the above information, I agree that, Dr. Sorin Mitrana’s Dental Office, can collect, use and disclose personal information about myself, and my family, as set out in the information about office’s privacy policies.
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new patient form

Country Park Dental

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Country Park Dental

HOW OUR OFFICE COLLECTS, USES AND DISCLOSES PATIENT’S PERSONAL INFORMATION

COUNTRY PARK DENTAL

PATIENT IS RESPONSIBLE FOR OWN DENTAL INSURANCE