Privacy & Consent Agreement

    Donly Dental takes your privacy of personal information very seriously and understand the importance of protecting your privacy. Our office complies with the Federal privacy legislation - the Personal Information and Protection and Electronic Documents Act (PIPEDA).

    Consent Acknowledgment

    Having read and understood the PRIVACY STATEMENT FOR PATIENTS, I consent to the collection, use and disclosure of my personal information as presented in the STATEMENT.

    I AgreeI Disagree

    Your Name:

    Your Email:

    Date of Birth:


    EDI Claims Consent

    I authorize release; to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to Dr R. Gupta, Donly Dental.

    I AgreeI Disagree


    Assignment Claims Consent

    I hereby assign my benefits, payable from claims submitted electronically, to Dr. Gupta, Donly Dental and authorize payment directly to him.

    I AgreeI Disagree


    Text and/or Email Consent

    I acknowledge Donly Dental may contact me via text messaging and/or email for confirmation of upcoming appointments, reminders, birthday greetings, etc.

    I AgreeI Disagree


    Patient/Parent/Guardian Signature

    Signature of patient, parent or guardian:
    Use your mouse to sign on computer, or finger on a mobile device


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    Monday:

    8:00am – 7:00pm

    Tuesday:

    8:00am – 7:00pm

    Wednesday:

    8:00am – 7:00pm

    Thursday:

    8:00pm – 7:00pm

    Friday:

    8:00am – 5:00pm

    Saturday:

    By Appointment Only

    Coming from out of town? Follow directions to Donly Dental. Now welcoming new dental patients from Delhi and Port Dover!

    Fill out this form and we'll get right back to you!





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