Policies/Consent Form - Rubinoff's Mighty Molars

(Please print, fill out, and bring forms to office upon appointment)

Patient Registration Sheet
(Click to download Adobe PDF)

To make your child's first appointment quicker please feel free to print out the following Patient Registration Sheet and Food Intake Diary, fill it out and hand it to reception upon your arrival. Instructions how to fill out your child's Food Intake Diary can be found below:

Food Intake Diary
(Click to download Adobe PDF)

Food Intake Diary Instructions:

1.	Please record all foods consumed for five consecutive days, including one weekend day or a holiday. For example, meals and snacks maybe recorded over a period Sunday to Thursday, or Tuesday to Saturday.
2.	Record everything that you eat or drink, including candies, gum, soft drinks and water.
3.	Be specific. For every item consumed please record:
	(a) The time
	(b) The kind of food (chicken, apple, gum, etc.) and the ingredients in mixed dishes such as lasagna and stew.
	(c) The amount in household measures (cup, ounces, tablespoon, teaspoon) or a rough estimate of size (one small orange, half a carrot, 1/8 of a pie).
	(d) The method of preparation (raw, bakes, fried, etc.)
	(e) The order in which foods were eaten
	(f) The number of teaspoons of suger, honey, or other suger products that are eaten or added to cereal, beverages or other foods.
4.	Record the times of tooth brushing.

Patient Privacy Consent Form
(Click to download Adobe PDF)

For Collection, Use and Disclosure of Personal information

Privacy of your personal information is an essential part of our office providing you with quality care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also try to be open and transparent as possible about the way we handle your personal information. It is important to us to provide this service to our patients.

In this office, the Privacy Information Officer is: Dr. Barry Rubinoff

All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protections of your information.

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

Only necessary information is collected about you;
We only share your information with your consent;
Storage, retention and destruction of your personal information complies with existing legislation, and privacy protocols;
Our policy protocols comply with privacy legislation, standards of our regulatory body and the law.

Do not hesitate to discuss our policies with Dr. Rubinoff or any member of our office staff. Please be assured that every staff person in our office is committed to ensuring that you receive the best quality care.

How Our Office Collects, Uses and Discloses Patients' Personal Information:

Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined below how our office is using and disclosing your information.

This office will collect, use and disclose information about you for the following purposes:

To deliver safe and efficient patient care
To identify and to ensure continuous high quality service
To asses your health needs
To provide health care
To advise you of treatment options
To enable us to contact you
To establish and maintain communication with you
To offer and provide treatment, care and services
To communicate with other treating health-care providers, including specialists and referring doctors
To allow us to maintain communication and contact with you to distribute health-care information and to book and confirm appointments
To allow us to efficiently follow-up for treatment, care and billing
For teaching and demonstrating purposes on an anonymous basis
To complete and submit claims for third party adjudication and payment
To comply with legal and regulatory requirements, including the delivery of patients' charts and records to governing bodies in a timely fashion, when required, according to the provisions of the Regulated Health Professions Act
To comply with agreements/undertakings entered into voluntarily by the member with governing bodies, including the delivery and/or review of patients' charts and records in a timely fashion for regulatory and monitoring purposes
To permit potential purchasers, practice bookers or advisors to evaluate the practice
To allow potential purchasers, practice bookers or advisors to conduct an audit in preparation for a practice sale
To deliver your charts and records to the office's insurance carrier to enable the insurance company to assess liabilities and quantify damages, if any
To prepare materials for the Health Professions Appeal and Review Board (HPARB)
To invoice for goods and services
To process credit card payments
To collect unpaid accounts
To assist this office to comply with all regulatory requirements
To comply generally with the law