First Visit

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.

Personal Information

We collect information from our patients such as names, home addresses, work addresses, 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 orthodontic services, to process credit card payments and issue receipts, or to collect unpaid accounts.
• To process claims for payment or reimbursement from third-party health benefit providers and insurance companies
• To send appointment reminders by telephone, text and email, as well as general email communication and video conferencing.
• Contact information is and may be disclosed to the following third parties:
• Referral to medical and/or dental practitioners for multidisciplinary treatments which coincide with dental treatments.
• Communications to health benefit providers and insurance companies on the patient’s behalf.
• Financial and credit card institutions for arrangements of the payment of dental services.
• Computer software companies (which may be nationally or internationally based) for storage and management of patient contact and financial information.

Medical Information

We collect information from our patients about their health history, their family health history, physical condition, and orthodontic treatment. (Collectively referred to as “Medical Information”). Patients’ Medical Information is collected and used for the purpose of diagnosing dental conditions and providing orthodontic 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 orthodontic treatment or has asked us to submit a claim on the patient’s behalf.
• To other dentists, dental specialists, and health care professionals, where a referral to/from or request to/from is required, and the patient has consented to Dr. Norman Thie obtaining or sharing medical information, pertinent to treatment, training or educational purposes.
• To a preferred dental provider, when a patient has advised that they are relocating or transferring to another location.
• Computer software vendors (which may be nationally or internationally based) for storage and management of patient treatment findings, imaging and medical files.
• For the use of case studies and treatment promotional material

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 and dental specialists 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. By typing my name below, I am electronically signing and certifying that I am in understanding of all of the above statements