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 Please make sure you've filled out all of the required fields. If you are still having trouble submitting the form, you can try a different browser. (Chrome is recommended).