Welcome! In order to render the best care possible it is necessary that we get to know you a little better. Of course all of this info is confidential. We appreciate you taking the time to fill out this form. (Double Sided)
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I give consent to Elmwood Park Dental for my Insurance Company to be contacted to help me get optimum coverage details and treatment predetermination responses sent to Elmwood Park Dental in a timely manner.
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OFFICE PHILOSOPHY AND POLICY: (Please Read)
In an effort to determine a treatment plan that is best for your overall dental health, we must make a careful diagnosis.
This involves a thorough examination, often utilizing the minimum number of X-rays necessary for accuracy. • We pledge to provide high quality dentistry in the most comfortable manner possible, with the best equipment, materials
and up to date techniques. • The long term success of our effort will depend on the patients' willingness to maintain their teeth and prevent any future
dental problems. • Your appointment time will be reserved especially for you. If you are unable to keep the appointment, we require 48
hours’ notice; or a $75.00 charge may be applied. We do NOT accept cancellation through voicemail. • Our office policy is that services are paid for at each visit as they are performed. In certain circumstances, financial
arrangements for payment may be made by consulting the patient care coordinator. •
Insurance: All patients with dental insurance are responsible for payment of their own accounts. We are pleased that you
have insurance to reimburse or minimize your personal expenditure and we will gladly complete any claim forms to assist
you in coordinating your dental benefits. Please make certain you understand any limitations in your contract. We will
gladly submit 'estimate forms, if necessary. • All urgent dental problems will be attended to the same day, under normal circumstances. You may call our office or
answering service at any time. •
A healthy dentist-patient relationship is based on mutual respect and understanding. Please feel relaxed and open to
discuss with us, any aspect of your treatment or fees, at any time.
CONSENT FOR TREATMENT
This is to certify that I consent to the performing of all dental procedures agreed to be necessary and I will assume responsibility for
all fees associated with all procedures.
Consent Form: Collection, Use and Disclosure of Personal Information (PIPEDA)
The privacy of personal information is an important part of our daily practice in providing you with quality dental
care. We are committed to collecting, using and disclosing your personal information responsibly while being as
open and transparent as possible about the way we handle your personal information.
Our office is committed to:
• Only collect necessary information about you. • We only share your information with your consent. • The 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. In this office, Dr. A Hughes acts as the Privacy information officer. Do not hesitate to discuss our policies with Dr. A
Hughes or any member of our staff. Please be assured that every staff member is committed to ensuring that you
receive the best quality dental care.
How our Office Collects, Uses and Discloses Patient’s Personal Information
Your privacy is important to us. To help you understand how we are protecting your information, we have outlined
below how our office is using and disclosing your information.
The 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 of service.
• To assess your health needs and to provide health care. • To advise you of your treatment options. • To enable us to contact you and to establish and maintain commutation with you. • To offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and
dental care referring dentists and / or peripheral dentists. • To allow us to maintain contact you to distribute healthcare information and to book confirm
appointments. This may include sending postcard type- reminders through the mail. • To allow us to efficiently follow up for treatment, care and billing. • To complete/submit predetermination and dental clams for third party adjudication and payment; to
provide further information that your insurer may request to aid in the processing claims. • To comply with legal and regulatory requirements, including the delivery of patient’s charts and records
to The Royal College of Dental Surgeons of Ontario in a timely fashion, when required and records to the
provisions of the Regulated Health Professionals Act. • To comply with the agreements/ undertakings entered into the voluntary by the member with the Royal
Collage of Dental surgeons of Ontario, Including the delivery and/ or review of patient’s charts and
records to the college in a timely fashion or regulatory monitoring purposes. • To permit potential purchasers, practice brokers and advisors to conduct and audit in preparation for a
practice sale. • To deliver your charts and records to the dentists insurance carrier to enable the insurance company to
access liability and quantity of damage, if any; • To prepare materials for the Health Professionals Appeal and Review Board (HPARB). • To invoice for goods and services. • To process credit card payments. • To collect unpaid accounts. • To assist this office to comply with all regulatory requirements. • To comply with the law. By signing this consent form, you have agree and consent to the collection, use and / or disclosure of your personal
information for the purposes that are listed above. If any new purpose arises for the use and/ or disclosure of your
personal information, we will seek your approval in advance.
Your information may be assessed by regulatory authorities under the terms of the Regulated Health Professionals
Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the
RHPA, and for the defense of a legal issue.
Our office will not under any conditions supply your insurer with your confidential medical history. In the event
this kind of request is made, we will forward this information directly for your review, and for your specific
consent. When unusual requests are received, we will contact you for your permission to release any information.
We may also advise you if such release is inappropriate.
You may withdraw your consent for use or disclosure of you personal information, and we will explain the
ramifications of the decision along with following steps.
LOCAL ANESTHESIA: May cause reactions like: Bruising, Hematoma, Cardiac Stimulation, Temporary, or rarely permanent numbness of the tongue, lips, teeth, jaw and/ or facial tissue or muscle soreness.