Office Consent form – Renewal

Cancellation policy
At Southport Dental Care, we put our faith in you to attend the appointments that you schedule with us. When we set up an appointment, a specific amount of time is reserved especially for you. Our office requires a minimum of 24 hours notice to reschedule or cancel an appointment. If 48 hours notice is not provided to change or cancel an appointment your account will be charged a fee.

Personal Information Consent
The complete original signed Personal Information Consent form for Southport Dental Care is available for review upon request. As a review, the information collected from our patients about their health history, family health history, physical conditions and dental treatments (collectively referred to as ‘Medical Information’) is used solely for the purpose of diagnosing dental conditions and providing appropriate dental treatment. It may be used in contacting other medical or dental specialists when seeking a second opinion or for the purposes of referring our patients for further treatment (if the patient has consented). It may be disclosed to third party health benefit providers and insurance companies.

Use of email / cell phone
Email addresses and cell phone numbers are used by our office as a means of communicating with our patients for various reasons, most commonly for confirming appointments and to keep our patients informed about changes in our scheduling. By providing your email and/or cell phone number to us you consent to them being used for this purpose. If you would not like to be contacted via these means please inform the administrative team of Southport Dental Care so that they can remove you from this service.

Treatments
Email addresses and cell phone numbers are used by our office as a means of communicating with our patients for various reasons, most commonly for confirming appointments and to keep our patients informed about changes in our scheduling. By providing your email and/or cell phone number to us you consent to them being used for this purpose. If you would not like to be contacted via these means please inform the administrative team of Southport Dental Care so that they can remove you from this service.

I understand that dentistry is not an exact science and that there can be no guarantees of treatment outcomes. I further acknowledge that no guarantees or assurances have been made regarding the treatment that I have consented to. I have had an opportunity to read this form and ask questions and accept that my questions have been answered to my satisfaction.

Patient Name:
Signed:
Date:
This information is collected under the authority of the Freedom of Information + Protection of Privacy Act Section 33(c). If you have any questions about collection of your personal information please contact our Office Manager or Dr. David Cichon directly at (403) 255-3202.