General Consent Form

TO OUR PATIENTS:Jensen Lakes Dental is committed to providing quality care and taking all possible steps in protecting the privacy of the patients and their personal information. All personal information collected will be used in a reasonable, professional manner. The purpose of this document is to summarize the personal information that will be collected, used, and disclosed by Jensen Lakes Dental. In addition to what is stated in this document, Jensen Lakes Dental will also collect, use, and disclose personal information when required to by law. All members of Jensen Lakes Dental ensure strict compliance with the regulatory and ethical guidelines set by the Alberta Dental Association and the Health Information Act Legislation.

PATIENT PRIVACY:Jensen Lakes Dental understands the importance of privacy regarding personal information and is committed to collecting, using, and disclosing the information in a responsible manner. This office ensures that: • Only information that is absolutely necessary will be collected • Your information will only be shared with your consent • Retention and destruction of your personal information is in compliance with the existing legislature and privacy protocols • The privacy protocols are in compliance with the law

CONTACT INFORMATIONThe information collected from our patients (names, home address, work address, telephone numbers, email addresses) referred to as contact information serves the following purpose at Jensen Lakes Dental: • To open patient files and keep them current • To send claims to insurance companies • To process payments • To remind patients of future dental exams/treatments/necessary preparations for appointments This information will be disclosed to third party providers and insurance companies where the patient has designated a claim to be submitted on their behalf. Financial information could be collected to make payment arrangements for dental services.

MEDICAL INFORMATION:Health history, family health history, physical and dental treatments and conditions are collected and used to determine or diagnose dental conditions and provide dental treatment. It is also used to ensure the medical safety of the patient while undergoing treatment The disclosure of medical information could happen if: • Jensen Lakes Dental is submitting an insurance claim on the patient’s behalf • The patient consents to getting a second opinion from another dentist or specialist • The patient consents to being referred to another dentist or specialist • The patient has been referred to Jensen Lakes Dental by a physician or non-dental specialist Dentists are regulated by the Alberta Dental Association and College which regulates the records and interviews staff as part of their office regulatory activities for the benefit of public interest.

PHOTOGRAPHY/ RADIOGRAPHYStandard headshots, videos, and intra-oral photography/radiography are all used as a part of the Jensen Lakes Dental routine examination process. These portions of the exam are utilized in the following ways: •By Jensen Lakes Dental and any other of the patient’s health care providers for diagnosis • Patient Education (the visualization of every step of the process, further understanding of what is being treated, and treatment progression) • Aiding in treatment planning (so dental team members can visualize the patient’s teeth while working on the patient’s case while the patient isn’t in the office) • To share with other health care professionals or at lectures (with identifying features removed) to scientific or medical audiences for educational purposes

STERILIZATIONJensen Lakes Dental takes the control of infection extremely seriously and has therefore made every effort to obtain and use the best sterilization machines/services as possible which meet and/or exceed the regulations set forth by the Alberta Dental Associate and College.

PAYMENT/ INSURANCEFor your convenience, Jensen Lakes Dental is able to direct bill on the patient’s behalf. As Jensen Lakes Dental is a third party, in order to take on the responsibility of direct billing we require to keep a copy of your insurance card information on file as well as all Patient Information to be fully completed and correct. It is also the responsibility of the patient to predetermine coverage limits with their insurance provider prior to treatment. If a predetermination of benefits has not been received or brought in to Jensen Lakes Dental, Jensen Lakes Dental is authorized to collect a 30% copay at the time of treatment. If any balance further remains once payment has been received from the insurance company, Jensen Lakes Dental will contact the patient to authorize the remaining payment to be made. If payment is not made after 30 days of initial attempt to notify patient about the outstanding balance, Jensen Lakes Dental has the right to charge collection costs (30% of outstanding balance + sales tax) and reasonable attorney fees incurred in attempting to collect on outstanding balance. If you wish to do non-assignment (Not Direct Billing), all payments must be made in full to Jensen Lakes Dental at the time of treatment. For your convenience, we accept cash, debit, VISA, and Mastercard. After payment has been made, all necessary paperwork will be provided to submit to the insurance company.

LATE/ CANCELLATIONPolicy Out of respect for all patients as well as the staff of Jensen Lakes Dental, if a patient is to arrive more than 15 minutes late to their appointment, Jensen Lakes Dental reserves the right to decline to see you. The appointment may be rescheduled. If you are unable to make it to an appointment, please let us know you would like to cancel more than 24 hours prior to the scheduled appointment time. If a patient continuously cancels within 24 hours of their designated appointment time, Jensen Lakes Dental has the right to refuse service to that patient.

ACKNOWLEDGEMENTSI acknowledge that I am aware of the reasons for my information being taken and understand that refusing to provide any of this information will result in the inability of the dentist to properly administer my oral care.

CONSENTI understand and consent to all of the above. I also understand that I can revoke my consent at any time, but if I decide to do so it must be in writing and signed by myself (patient or guardian) and presented to the Jensen Lakes Dental Clinic. 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 the dentists at Jensen Lakes Dental.