Medical History Form
Privacy of your personal health information is an important part of our office providing you with quality
dental care. We understand the importance of protecting your personal health information. We are
committed to collecting, using, and disclosing your personal health information responsibly. We also try
to be as open and transparent as possible about the way we handle your personal health information. It
is important to us to provide this service to our patients.
In this office, Dr. Nagham is the contact person for personal health information-related matters.
All staff members who come in contact with your personal health information are aware of the sensitive
nature of the information that you have disclosed to us. They are all trained in the appropriate uses and
protection of your information. Attached to this consent form, we have outlined what our office is doing
to ensure that:
- only necessary information is collected about you;
- we only share your information with your consent;
- storage, retention, and destruction of your personal health information complies with existing
legislation, and privacy protection protocols;
- our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal
College of Dental Surgeons of Ontario, and the law.
Do not hesitate to discuss our policies with me or any member of our office staff.
How Our Office Collects, Uses, and Discloses Patients’ Personal Health Information
Our office understands the importance of protecting your personal health information. To help you
understand how we are doing that, we have outlined here how our office is using and disclosing your
This office will collect, use and disclose personal health information about you for the following
- to deliver safe and efficient patient care
- to identify and to ensure continuous high-quality service
- to assess your health needs
- to provide health care
- to advise you of treatment options
- to enable us to contact you
- to establish and maintain communication with you
- to offer and provide treatment, care, and services about the oral and maxillofacial complex
and dental care generally
- to communicate with other treating health care providers, including specialists and general dentists
who are the referring dentists and/or peripheral dentists
- to allow us to maintain communication and contact with you to distribute health care information and
to book and confirm appointments
- to allow us to efficiently follow-up for treatment, care, and billing
- for teaching and demonstrating purposes on an anonymous basis
- to complete and submit dental claims for third party adjudication and payment
- to comply with legal and regulatory requirements, including the delivery of patients’ charts and records
to the Royal College of Dental Surgeons of Ontario in a timely fashion, when required, according to the
provisions of the Regulated Health Professions Act
- to comply with agreements/undertakings entered into voluntarily by the member with the Royal
College of Dental Surgeons of Ontario, including the delivery and/or review of patients’ charts and
records to the College in a timely fashion for regulatory and monitoring purposes
- to permit potential purchasers, practice brokers, or advisors to evaluate the dental practice
- to allow potential purchasers, practice brokers, or advisors to conduct an audit in preparation for a
- to deliver your charts and records to the dentist’s insurance carrier to enable the insurance company to
assess liability and quantify damages, if any
- to prepare materials for the Health Professions Appeal and Review Board (HPARB)
- to invoice for goods and services
- to process credit card payments
- to collect unpaid accounts
- to assist this office to comply with all regulatory requirements
- to comply generally with the law
By signing the consent section of this Patient Consent Form, you have agreed that you have given your
informed consent to the collection, use, and/or disclosure of your personal health information for the
purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal health
information, we will seek your approval in advance.
Your personal health information may be accessed by regulatory authorities under the terms of the
Regulated Health Professions Act (RHPA) for the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA.
You may withdraw your consent for the use or disclosure of your personal health information at any time.
I have reviewed the above information that explains how your office will use my personal health
information, and the steps your office is taking to protect my information.