Our office understands the importance of protecting your personal information. This office will collect, use and disclose information about you for the following purposes:
- To enable us to contact you (your child) and to book and confirm appointments
- To advise you of treatment options
- To communicate with other health-care providers, including medical and dental specialists and general practitioners
- 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 Regulatory Health Professions Act.
- To comply with agreements/undertakings entered into voluntarily by Dr. Stefan Ciz 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 prepare material for the Health Professions Appeal and Review Board
- To process credit card payments
- To collect unpaid accounts
You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision, and the process.
By signing the consent section of this form, you have agreed that you have given your informed consent to collection, use and/or disclosure of your personal information for the purposes that are listed.
I have reviewed the above information that explains how your office will use my personal information. I know that your office has a Privacy Code, and I can ask to see the Code at any time. I agree that Dr. Stefan Ciz can collect, use and disclose personal information as set out above in the information about the office’s privacy policies according to the requirements of the Regulated Health Professions Act, the Royal College of Dental Surgeons and privacy legislation.