Privacy & Consent Agreement Form

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:
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