Patient Consent Form – Collection, Use and Disclosure of Personal Information

As dental professionals, we are required to comply with Federal and Provincial Privacy Legislation, (PIPEDA) and (PHIPA). In order to do so, each of our patients must sign a consent form acknowledging and allowing us to collect, use and disclose personal information according to specific guidelines. At Lenga Perio, the privacy of your personal information is of utmost importance. We are committed to collecting, using and disclosing your personal information responsibly. Our policies regarding your personal information are open and


In this office, Dr. Yair Lenga acts as the Privacy Information Officer. All staff members are aware of the sensitive nature of the information that you have disclosed to us. They are trained in the appropriate uses and protection of your information; we are committed to adhering closely to our Privacy Code. Please do not hesitate to discuss and review our policies and Privacy Code with any member of our team.


We limit the collection of personal information to only the relevant and necessary information. Your personal information will be stored, retained and destroyed in compliance with the existing legislation and privacy protection protocols of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the federal legislation of the Personal Information Protection and
Electronic Documents Act (PIPEDA).


  • In our office we will collect, use and disclose your personal information for the following purposes:
  • to accurately assess your overall medical and dental health in order to provide safe, efficient, quality orthodontic and dentofacial orthopedic assessment, diagnosis and treatment
  • to establish and maintain communication with you in regards to all aspects of your care, including assessment, diagnosis, treatment, and your financial matters
  • to communicate with your team of health care professionals (e.g. general dentists, dental specialists, medical doctors) in order to provide the highest level of comprehensive care in a cohesive manner
  • for teaching and demonstrating purposes on an anonymous basis
    to comply with all legal and regulatory requirements of provincial and federal laws
  • to comply with all regulations set forth by the Royal College of Dental Surgeons of Ontario


Patient Acknowledgement and Consent 

Patient or Parent/Guardian First Name(Required)
Patient or Parent/Guardian Last Name(Required)
Witness First Name(Required)
Witness Last Name(Required)
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.