Monday to Thursday from 8:00 AM to 4:30 PM, Closed Friday - Sunday

(905) 725-5088

PATIENT CONSENT FORM

FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

Privacy of your personal information is an important part of THE PERIO CENTRE providing you with quality dental care. We understand the importance of protecting your personal information. We are committed to collecting, using, and disclosing your personal information responsibly. We also try to be open and transparent as possible about the way we handle personal information. It is important to us to provide this service to our patients.

In this office, Dr Adam Ohayon, acts as the Privacy Information Officer.

All staff members who encounter personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate use and protection of your information.

Attached to this consent form, we have outlined what The Perio Centre is doing to ensure that:

Do not hesitate to discuss our policies with any member of our staff.

Please be assured that every staff member in our office is committed to ensuring that you receive the best quality of dental care.

The Perio Centre understands the importance of protection 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.

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

By signing the consent section of the 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

Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professions 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 legal issues.

You may withdraw your consent for use and disclosure of your personal information at any time. At that time, we will explain the ramifications of the decision


PATIENT CONSENT

I have reviewed the above information that explains how The Perio Centre will use my personal information, and the steps your office is taking to protect my information

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