Patient Consent Form

Kelowna Denture Clinic (the “Clinic”) is committed to protecting the privacy of our patients’ Personal Information and to utilizing all Personal Information in a responsible and professional manner and in accordance with British Columbia’s Personal Information and Protection Act (“PIPA”). The following indicates some of the information that is collected, why the Clinic collects it, and when the Clinic may disclose your personal information.

Contact Information

The Clinic will collect contact information for its patients, including but not limited to: names, home addresses, work addresses, home telephone numbers, work telephone numbers, and email addresses (“Contact Information”). Contact Information is collected and used for the purposes of:

• Opening and updating patient files;
• Invoicing patients for dental services, including processing credit card payments or collecting unpaid accounts;
• Processing claims for payment or reimbursement from third party health benefit providers and insurance companies, including by electronic submission;
• correspondences to patients concerning further or future dental examination or treatment; and
• Sending patients information material about the Clinic and practice.

Personal Information

The Clinic will collect, use, and/or disclose Personal Information for purposes that a reasonable person would consider appropriate in the circumstances and as permitted by PIPA.

Personal information means information about an identifiable individual and includes employee personal information, including but not limited to: an individual’s age, date of birth, health information, including medical records including medical or dental health history, family health or dental health history, physical condition, and dental treatments, and financial information (collectively known as “Personal Information”).

In particular, the Clinic collects from its patients the following information: information about their health history, family health history, physical and mental condition, their dental health history, and family dental health history. This medical/dental information is collected for a variety of purposes (listed in full here) and may be used in part to assist in diagnosing dental conditions and providing appropriate treatment for you, and may be disclosed for the following purposes:

• To a third-party health benefit provider or insurance company, in the submission of a claim on behalf of the patient, for reimbursement or payment of all or part of the cost of the treatment OR in the submission of a pre-authorization of treatment;
• To other health/dental providers where, upon your consent, we are seeking a second opinion, OR where we have referred you to another health/dental provider for additional or alternative treatment.

Financial Information

The Clinic collects information related to financial matters in order to facilitate payment of your treatment(s).

Future Use

If the practice or a portion of the Clinic or its practice is being considered for sale, any qualified potential purchaser may be granted access to patient information, in order to verify information related to the Sale. If this ever occurs, we will take necessary steps to ensure that the prospective purchaser protects any personal information, as we have.

Regulatory

Provincial regulatory bodies may inspect Clinic records and interview Clinic staff in carrying out their duties.

Anti-Spam

When the Clinic communicates with you, we may communicate via electronic means, such as email. By signing below, you agree to allow the Clinic to communicate with you via email. Additional details on our Anti-Spam Policy is found in the attached Patient Privacy and Anti-Spam Policy.

Consent

I hereby authorize and consent to the collection, use, and disclosure of my personal information by the Clinic for the purposes outlined above (and for the purposes outlined in the attached Patient Privacy and Anti-Spam Policy). I understand and acknowledge that all information collected may be viewed by persons employed at the Clinic to assist in record keeping within the scope of their job.