* For information purposes only:                
               IMPLANT SMILE CENTER
   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 address, work address, home telephone numbers, work telephone numbers, and e-mail addresses (collectively referred to as "Contact Information"). Contact Information is collected and used for the following purposes:

* To open and update patient files.
* To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts.
* To process claims for payment or reimbursement from third-party health benefit providers and insurance
companies.
* To send reminders to patients concerning the need for further dental examination or treatment.
* To send patients informational material about our dental practice or information relating to dental health.

Contact Information is 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 dental treatment, or has asked us to submit a claim on the patient’s behalf. Financial information may be collected in order to make arrangements for the payment of dental services.
We collect information from our patients about their health history, their family health history, physical
condition, and dental treatments (collectively referred to as "Medical Information"). Patients’ Medical
Information is collected and used for the purpose of diagnosing dental conditions and providing dental
treatment.

Patients’ Medical Information is 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 dental treatment, or has asked us to submit a claim
on the patient’s behalf.
* To other dentists and dental specialists, where we are seeking a second opinion and the patient has
consented to us obtaining the second opinion.
* To other dentists and dental specialists if the patient, with their consent, has been referred by us to the other
dentist or dental specialist for treatment.
* To other dentists and dental specialists where those dentists have asked us, with the consent of the patient,
to provide a second opinion.
* To other health care professionals such as a physician if the patient, with their consent, has been referred by
us to the other health care professional for either a second opinion or treatment.

If we are ever considering selling all or part of our dental 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 are regulated by the Alberta Dental Association and College, which may inspect our records and interview our staff 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.

____________________         ___________________________         ___________________________

Date                                     Print Name                                        Signature

                                                                                                                                                   R.E. LEIGH Professional Corp. ®

                                    

Our Personal Information Procedures

We have appointed a Privacy Officer as our principal advisor and issues manager regarding personal information protection. On your behalf, our staff is trained in personal information protection. We review our information collection procedures and consent forms on an ongoing basis, and we ensure that any contractors we hire who might have access to your personal information also take steps to protect the privacy of your personal information. At the Implant Smile Center we have a privacy policy in place for patients and employees. The Personal Information Protection Procedures below tell you how we fulfill the commitment to patients in our Privacy Policy at the Implant Smile Center Dental Health Clinic.

Protection of Your Personal Information in Our Records

Our records containing your personal information are stored in a secure place.
Our electronic records are stored on hardware that is secure. Passwords are used on all of our computers.
We take care to protect screen monitors from public viewing in the office.
Paper records are transferred outside our office in sealed envelopes by secure methods and with reputable carriers.
Telephone discussions with patients in the office are carried on with sensitivity to protecting personal information.
Electronic information is transferred in secure files, and sent anonymously wherever possible.
We do not share your personal information outside our office for any marketing, promotional, publicity, educational or
research purposes without your consent.
Our staff is trained to handle your information only through the protective measures outlined in our privacy procedures.
If we hire consultants or contractors who might have access to any of your personal information, we will take steps to
ensure that the consultant or contractor takes steps to protect the privacy of your personal information.

Storage and Destruction of Personal information

We are required by legislation and regulation to keep records containing personal information for specified periods of time.
We keep your records for a maximum of 10 years from your last service, even if you move from our office.
We destroy personal information in paper records by shredding it. We destroy electronic personal information by deleting it.
When discarding hardware, we make sure the hard drive is destroyed.