Consent for Collection, Use and Disclosure of Personal Information

Sarah Robertson-Smith R.D.H.

Protecting the privacy of your personal information is a priority. Sarah is the privacy officer.

Policies and procedures are followed to ensure confidentiality and safe record keeping.

Storage, retention and destruction of your personal records comply with current legislation and laws in Ontario. This is outlined in the Personal Health Information Protection Act 2004, Regulated Health Professions Act, and guidelines set by the College Of Dental Hygienists Of Ontario.

Muskoka Gentle Dental is committed to protecting your personal information in a responsible and professional manner.

Generally your personal information is required to complete a full medical and dental history.

Your personal health information or dental hygiene assessment findings will Not be shared without your permission. (Unless you sign the General Release Statement – Long Term Care Facility)

The Clients’ confidentiality of records and services as well as their privacy are up held in a professional manner in accordance with the College of Dental Hygienists Of Ontario, and the Registered Dental Hygienist. Your information allows the Registered Dental Hygienist to:

  • Provide safe dental hygiene care – formulation of treatment plans by reviewing your medical and dental history to understand your unique health needs.
  • Self-initiation allows the R.D.H. to follow guidelines ensuring no contraindications exist in providing preventive care.
  • To help understand important connections related to homecare skills/methods.
  • To allow the R.D.H. to contact you.
  • To complete and submit insurance claim forms
  • To comply with the C.D.H.O. in case of professional audit.
  • To collect unpaid accounts and to generally comply with the law
  • By signing this consent form you have agreed that you have given informed consent to the collection, use/ disclosure of your personal information. No one else will have the right to review your personal information without your consent. I have reviewed the following information and understand why this information is required. I agree that Sarah Robertson Smith R.D.H. can collect, use and disclose personal information about:
  • MM slash DD slash YYYY
  • General Release Statement – Long Term Care Facility Circle of care involves individuals who participate in the care of a resident in a long-term care facility. Best Practice guidelines will allow the R.D.H. to communicate with other healthcare providers such as - R.N. / R.P.N. / P.S.W. their Physician, Dentist, Pharmacist, Denturist and/ or Director of Care for the facility. The dental hygiene assessment exam findings, DH diagnosis, planning, implementation, evaluation of treatment planning and daily oral care recommendations: could be communicated with these individuals. This will facilitate effective communication between the providers of care and address oral care issues for residents who cannot communicate their dental concerns related to dementia, behavioural or for any other personal reason. The R.D.H. will work closely with the resident’s daily care providers to help formulate an oral care plan to ensure interventions for DAILY mouth care will be met and I will provide support, consultation, and referral if necessary. Best practice guidelines will be followed as regulated by the College of Dental Hygienists of Ontario and also to be implemented is the oral health nursing assessment and interventions guidelines for use in the Long-Term care setting recommended by the R.N.A.O. (Registered Nurses Association of Ontario), and the Long Term Care Act of Ontario. I authorize the Registered Dental Hygienist to perform dental hygiene care within the scope of practice as outlined by the College of Dental Hygienists of Ontario. I consent to Dental Hygiene Assessment Exam to be implemented and understand the findings will help formulate the next steps regarding treatment planning. I understand that I am financially responsible to Muskoka Gentle Dental even if the dental insurance coverage may not be all inclusive.
  • All forms are submitted manually to the insurance company by mail. After treatment is rendered the dental hygiene treatment plan report and the insurance form is sent to the P.O.A’s current mailing address. Please contact Sarah Robertson-Smith R.D.H. directly if you have any questions.