Patient Consent Form

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Collection, Use and Disclosure of Personal Information

Email *

In our practice, we understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We aim to be open and transparent about the way we handle your personal information.

Dr. Marc Yarascavitch, representing Marc Edward Yarascavitch Dentistry Professional Corporation, provides the professional orthodontic services and technical health care services rendered at our office. All services are provided under the clinical supervision of Dr. Yarascavitch. All staff members are aware of the sensitive nature of the information that you have disclosed to us. They are trained in the appropriate uses and protection of your information; we are committed to adhering closely to our Privacy Code. In this office, Dr. Yarascavitch acts as the Privacy Information Officer. Please do not hesitate to discuss and review our policies and Privacy Code.

We limit the collection of personal information to only relevant and necessary information. Your personal information will be stored, retained and destroyed in compliance with existing legislation and privacy protection protocols of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the federal legislation of the Personal Information Protection and Electronic Documents Act (PIPEDA).

Dr. Yarascavitch will collect, use and disclose your personal information for the following purposes:

• To accurately assess your overall medical and dental health in order to provide safe, efficient, quality-driven orthodontic assessment, diagnosis and treatment
• To establish and maintain communication with you regarding all aspects of your care, including assessment, diagnosis, treatment, and your financial matters
• To communicate with your team of health care professionals (e.g. general dentists, dental specialists, medical doctors) in order to provide the highest level of comprehensive care
• To comply with all legal and regulatory requirements of the Royal College of Dental Surgeons and of Ontario provincial and federal laws

If you have any concerns and/or wish to inquire about our privacy practices, including asking questions about the contents of your charts or records, please feel free to ask. For a copy of your records, you must make your request in writing to Dr. Yarascavitch.

Patient Name *

I have reviewed the above information regarding the collection, use and disclosure of the personal information for the patient listed above. I give consent to Dr. Yarascavitch, to collect, use and disclose the personal information as described above, and in accordance with the Privacy Code of their office. *

Yes, I give my consent

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Patient or Parent/Guardian Signature (typing your full name will constitute your signature) *

Today's Date *

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Send me a copy of my responses.

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