This is to certify that I, the undersigned, consent to the performing of the dental procedures agreed to be necessary or advisable including the use of local anesthetic as indicated and I will assume responsibility for fees associated with those procedures.

Attached to this consent form, we have outlined what our office is doing to ensure that:

• check_circle Only necessary information is collected about you
• check_circle We only share your information with your consent
• check_circle Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols
• check_circle Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law.

In this office, DR. B. CHAGGER acts as the Privacy Information Officer.

Attached to this consent form, we have outlined what our office is doing to ensure that:

I have reviewed the above information that explains how your office will use my personal information, and the steps your office is taking to protect my information.

I know that your office has a Privacy Code, and I can ask to see the code at any time.