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).