Personal Information Consent

• Contact details: your name, home and work addresses, phone numbers and email.
• Health information: your medical and dental history, relevant family history, examination findings, x-rays, photos and treatment records.
• Financial and insurance details: what we need to arrange payment and submit claims.

• to create and update your patient record;
• to diagnose dental conditions and provide treatment;
• to bill for services, process payments, and collect unpaid accounts;
• to submit claims and pre-authorizations to your insurance or benefit plan;
• to remind you about appointments and checkups that are due; and
• to send you information about our practice.

We share only what is needed for the purpose:

• with your insurer or benefit plan, when you make a claim or ask us to make one for you;
• with other dentists, specialists or physicians, with your consent, when we refer you, ask for a second opinion, or are asked for one;
• with dental laboratories that make your crowns, dentures, aligners and similar items;
• with the Royal College of Dental Surgeons of Ontario, which may review records as part of its role in regulating dentists; and
• if the practice is ever being sold, with a serious potential buyer reviewing the practice, who must keep the information confidential.

Your choices: you may ask to see your record, ask us to correct it, or withdraw consent for some uses, such as practice news. Contact us at 226-884-2573 or info@lunarsmiledentistry.ca.

Your appointment time is set aside just for you. If you need to cancel or reschedule, please give us at least 48 hours notice so we can offer the time to another patient. Appointments cancelled with less than 48 hours notice, and missed appointments, are subject to a $50 fee, payable before your next appointment.