First Name(Required)MiddleLast Name(Required)Preferred NameI grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information, and clinical information) to the secured web site for the dental practice. I also understand that provincial laws, ethical and licensure requirements impose obligations with respect to patient confidentiality that limits the ability to make use of certain services or to transmit certain information to third parties. I understand that I give permission for email communications to myself and third parties based on my request. I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES. I have read the information above regarding the secured uploading of patient information to the website for the dental practice, and grant the dental practice permission to securely upload my patient information to the web site.confirmed(Required) Confirmed Patient, parent, or guardian:E-mail(Required)Relationship to PatientRelative NameDraw Your Signature(Required)By entering your full name, email address, and phone number, you agree with online transfer of information that will be used by Vancouver Dental Specialty Clinic for the sole purpose of returning your request to be contacted by us. Vancouver Dental Specialty Clinic takes no responsibility for web communication.
