Personal Information Consent Form

We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted or required by law.

We collect information from our patients such as names, home addresses, work addresses, home telephone, work telephone, cell phone numbers and e-mail addresses. (collectively referred to as “Contact Information”). Contact Information is collected and used for the following purposes:

• Management of patient contact and correspondence

• Invoicing for orthodontic services, processing credit card payments, issuing receipts, and/or to collect unpaid accounts.

• Processing claims for payment or reimbursement from third-party health benefit providers and insurance companies.

• Management of telephone and email appointment reminders, and email communication.

Contact information is and may be disclosed to the following third parties:

• Referral to medical and/or dental practitioner s for multidisciplinary treatments which coincide with orthodontic treatment.

• Communications to health benefit providers and insurance companies on the patient’s behalf.

• Financial institutions for arrangements of the payment of orthodontic services.

• Computer software companies (which may be nationally or internationally based) for storage and management of patient contact and financial information.

We collect information from our patients about their health history, their family health history, physical condition, and orthodontic treatment, including photos and x-rays. (Collectively referred to as “Medical Information”). Patients’ Medical Information is collected and used for the purpose of diagnosing dental conditions and providing orthodontic treatment and is used electronically, through secure and protected applications.

Patients’ Medical Information is and may be disclosed:

• To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of orthodontic treatment or has asked us to submit a claim on the patient’s behalf.

• To other dentists, dental specialists, and health care professionals, where a referral to/from or request to/from is required, and the patient has consented to Align Orthodontics obtaining or sharing of medical information, pertinent to treatment, training or educational purposes.

• To a preferred orthodontic specialist, when a patient has advised Align Orthodontics that they are moving.

• Computer software companies (which may be nationally or internationally based) for storage and management of patient treatment, imaging and medical files.

• For the use of case studies and treatment promotional material

If we are ever considering selling all or part of our orthodontic practice, qualified potential purchasers may be granted access as part of the due diligence process to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information.

Dentists and dental specialists are regulated by the Alberta Dental Association and College which may inspect our records and interview our employees as part of its regulatory activities in the public interest.

I consent to the collection, use and disclosure of my personal information as set out above. By typing my name below, I am electronically signing and certifying that I am in understanding of all of the above statements