Privacy Consent Form

Before your appointment, please review and complete our privacy consent form. This privacy consent form explains how Nordic Dentistry collects, uses, and protects your personal health information in accordance with Ontario’s privacy regulations.

Submitting our privacy consent form online saves time at your next visit and ensures our Kitchener team has your up-to-date consent on file. If you have any questions about the privacy consent form, please contact our office before your appointment.

PRIVACY CONSENT FORM

• I allow and provide consent to Nordic Dentistry to collect, use and disclose information about me for the following purposes:
  
• To deliver safe and efficient patient care
  
• To identify and to ensure continuous, high-quality services
  
• To assess my dental health needs
  
• To advise me of treatment options
  
• To enable Nordic Dentistry to contact me directly
  
• To establish and maintain communication with me
  
• To offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care
  
• To allow Nordic Dentistry to efficiently follow-up for treatment, care, and billing For teaching and demonstrating purposes on an anonymous basis
  
• To complete and submit electronic and/or paper dental claims for third party adjudication, pre-approval where necessary, and payment
  
• To permit dentists, practice brokers and/or advisors to evaluate the dental practice and conduct an audit in preparation for practice sale
  
• To invoice for goods and services
  
• To process credit card payments when there is a balance outstanding or when I call in and provide telephone authorization
  
• To provide Nordic Dentistry with insurance details, so we may receive a dental breakdown of the coverage. You are also responsible for any differences not paid by the insurance company, on the same day as the service is rendered.
  o If a patient’s account falls into arrears all reasonable collection fees will be the responsibility of the account holder, in addition to the arrears and possible service fee.
  
• I authorize Nordic Dentistry to post/advertise pictures within the office and on social media of myself or my child/dependent.
  
• I authorize release to my dental benefits plan administrator, information contained in claims submitted electronically.
  
• This authorization shall continue in effect until authorize the communication of information related to the coverage of services described to the named dentist.

Patient Name:(Required)

First Last

Signature (of patient or parent/guardian):(Required)

Date(Required)

MM slash DD slash YYYY

Why We Require a Privacy Consent Form

As a healthcare provider, we are required to obtain your consent before collecting, using, or sharing your personal health information. Completing this privacy consent form allows us to communicate with you, coordinate your care, and keep accurate records while respecting your privacy rights.

Frequently Asked Questions

Do I need to complete a new privacy consent form every visit?
No, you typically only need to complete the privacy consent form once, unless your information changes or our privacy policy is updated.

Is my information kept secure?
Yes. Information submitted through our privacy consent form is stored securely and is only accessible to authorized staff involved in your care.

Can I ask questions about how my information is used?
Absolutely. Our team is happy to explain any part of the privacy consent form or our privacy practices before you sign.