Patient Name:

At Mckenzie Dental Centre we are committed to protecting the privacy of our patient’s personal information and to utilizing all personal information in a responsible & professional manner. This document summarizes some of the personal information that we collect, use, & disclose. In addition to the circumstances described in this form, we also collect, use & disclose personal information when permitted or required by law.

We collect information from our patients such as names, home address, telephone numbers, and email addresses (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, collect unpaid accounts
• To process claims for payment from third party insurance & benefit providers
• To send reminders to patients concerning the need for further dental examination or treatment, including hygiene recall card reminders
• To send patients information on our practice such as patient news letters
Contact information is disclosed to third party health benefit providers & insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf.
Financial information may be collected in order to make arrangements for the payment of our services.

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

Patient’s Medical Information is disclosed:
• To third party benefit providers & insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf
• To other dentists and dental specialists, where we are seeking a second opinion & the patient has consent to us obtaining the second opinion
• To other dentists & dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion
• To other health care professionals such as physicians if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or treatment
If we are ever considering selling all or part of our dental practice, qualified potential purchaser 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 & College, which may inspect our records & interview our staff as part of its regulatory activities in the public interest.

   I CONSENT TO THE COLLECTION, USE & DISCLOSURE OF
MY PERSONAL INFORMATION AS SET OUT ABOVE.

Please note that the New Patient Form will be processed within 24 hours.

The form can be submitted via email or printed and brought in to your first visit.