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    Patient Information

    Name
















    Primary Insurance Information








    Secondary Insurance Information (if applicable)










    Medical & Dental History

































    X-RAY RELEASE FORM







    To release health care information of the patient name above, to:

    Monterey Dental Centre

    2220 68 St NE #826,

    Calgary, AB T1Y 6Y7

    Phone: (403) 293-7818

    Email: info@montereydental.ca

    This request and authorization apply to:

    • Copy of complete dental chart including periodontal measurements

    • Copy of dental x-rays (including Panoramic or FMS)

    I understand that my express consent is required to release any healthcare information relating to testing, diagnosis and treatment.

    Please note, the Supreme Court of Canada has ruled:

    “A patient is entitled to copies of their dental records provided a signed authorization is received….”

    Please forward all copies at your earliest convenience. I thank you in advance for your cooperation.




    Dental Office 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 in this form, we also collect, use and disclose personal information when permitted or required by law.

    Information is collected such as names; home and work addresses; home, work, and cell phone numbers, and e-mail addresses (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 materials

    • To follow up with treatment and/or customer services

    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.

    We collect information from our patients about their health history, family health history and their dental history. (Collectively referred to as “Medical Information”.) Medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment.

    Patients’ Medical Information is disclosed for the following purposes:

    • 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/specialists where we are seeking a second opinion or they have asked us to provide a second opinion and the patient has consented to this.

    • To other dentists/specialists if the patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment

    • I consent to the collection, use, and disclosure of my/our personal information as set out above.

    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/our personal information as set out above.